Mechanical Thrombectomy Is Now the Gold Standard for Acute Ischemic Stroke: Implications for Routine Clinical Practice

Abstract

Background: This review aims to summarize the findings of the recently published randomized controlled studies which provide overwhelming evidence in support of mechanical thrombectomy for acute ischemic stroke with large artery occlusion. The five studies, Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN), Endovascular Revascularization with Solitaire Device versus Best Medical Therapy in Anterior Circulation Stroke within 8 h (REVASCAT), Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE), Solitaire™ FR as Primary Treatment for Acute Ischemic Stroke (SWIFT PRIME) and Extending the Time for Thrombolysis in Emergency Neurological Deficits with Intra-Arterial Therapy (EXTEND IA) have demonstrated the critical role of selecting patients by advanced neuroimaging, the superior recanalization capacity of stent retrievers and the effects of minimization of work processes delay. Summary: This review outlines lessons gained from the 5 positive studies which assessed mechanical thrombectomy as part of endovascular therapy for patients with proximal artery occlusion in the internal carotid and middle cerebral arteries. It discusses the role of age and stroke severity on treatment while also comparing the unique trial designs and selection criteria used amongst the 5 studies. In addition to examining the importance of unique imaging parameters such as collateral circulation, mismatch ratio and ischemic core volume, the review outlines differences in workflow parameters within the context of outcome. Finally the benefit of neuroimaging to broaden treatment eligibility and the issues associated with general anesthesia will be discussed in this review. Key Messages: Questions remain over the applicability of mechanical thrombectomy to stroke subgroups including wake-up strokes and basilar artery thrombosis. The role of imaging is integral to this process and can lead to broadening eligibility criteria in the future. Workflow practices have been streamlined in the 5 positive randomized controlled studies, but guidelines will need to be revised accordingly if similar patient outcomes are to be replicated in a wider population.