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Neurothrombectomy in the treatment of acute ischaemic stroke

Nature Reviews Neurology volume 9, pages 645–652 (2013)Cite this article

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Abstract

Major ischaemic stroke is a leading cause of morbidity and mortality in industrialized countries. For patients with acute stroke, fast and effective vessel recanalization is important for successful treatment. Neurothrombectomy—that is, angiographically performed mechanical thrombus removal from intracranial arteries—results in higher recanalization rates than with pharmaceutical thrombolysis alone, but the value of this treatment in terms of clinical outcome remains to be established. This article summarizes the history of intra-arterial stroke treatment, outlines the recent developments and the different techniques used, and discusses the results of current studies on neurothrombectomy. Owing to the high morphological and clinical variability of stroke, careful patient selection in future randomized controlled trials will be crucial for assessment of the true potential of neurothrombectomy.

Key Points

  • Intravenous thrombolysis has limited effects on outcomes in patients with acute ischaemic stroke, mainly owing to insufficient ability of this drug to dissolve large thrombi

  • Several emerging angiographic techniques that aim to remove the thrombus from an occluded cerebral artery (neurothrombectomy) are under investigation

  • Recent studies suggest that neurothrombectomy can recanalize large cerebral arteries more quickly and effectively than does intravenous thrombolysis

  • Prospective controlled trials are required to determine whether neurothrombectomy as an adjunct to established therapy results in better patient outcomes

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Figure 1: CT imaging of acute left-hemispheric stroke.
Figure 2: Cerebral angiography of neurothrombectomy.
Figure 3: Thrombus specimen retrieved by neurothrombectomy.

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References

  1. Go, A. S. et al. Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation 127, e6–e245 (2012).

    PubMed  PubMed Central  Google Scholar 

  2. Mukherjee, D. & Patil, C. G. Epidemiology and the global burden of stroke. World Neurosurg. 76, S85–S90 (2011).

    Article  PubMed  Google Scholar 

  3. Fisher, M. Stroke and TIA: epidemiology, risk factors, and the need for early intervention. Am. J. Manag. Care 14, S204–S211 (2008).

    PubMed  Google Scholar 

  4. Moran, C., Phan, T. G. & Srikanth, V. K. Cerebral small vessel disease: a review of clinical, radiological, and histopathological phenotypes. Int. J. Stroke 7, 36–46 (2012).

    Article  PubMed  Google Scholar 

  5. Kruetzelmann, A. et al. Combining magnetic resonance imaging within six-hours of symptom of onset with clinical follow-up at 24 h improves prediction of 'malignant' middle cerebral artery infarction. Int. J. Stroke http://dx.doi.org/10.1111/ijs.12060.

  6. Grotta, J. & Marler, J. Intravenous rt-PA: a tenth anniversary reflection. Surg. Neurol. 68 (Suppl. 1), S12–S16 (2007).

    Article  PubMed  PubMed Central  Google Scholar 

  7. Hacke, W. et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA 274, 1017–1025 (1995).

    Article  CAS  PubMed  Google Scholar 

  8. Hacke, W. et al. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet 352, 1245–1251 (1998).

    Article  CAS  PubMed  Google Scholar 

  9. Hacke, W. et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N. Engl. J. Med. 359, 1317–1329 (2008).

    Article  CAS  PubMed  Google Scholar 

  10. [No authors listed] Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N. Engl. J. Med. 333, 1581–1587 (1995).

  11. Adams, H. P. Jr et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Circulation 115, e478–e534 (2007).

    Article  PubMed  Google Scholar 

  12. Del Zoppo, G. J., Saver, J. L., Jauch, E. C. & Adams, H. P. Jr. American Heart Association Stroke Council. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke 40, 2945–2948 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  13. Jansen, O., von Kummer, R., Forsting, M., Hacke, W. & Sartor, K. Thrombolytic therapy in acute occlusion of the intracranial internal carotid artery bifurcation. AJNR Am. J. Neuroradiol. 16, 1977–1986 (1995).

    CAS  PubMed  PubMed Central  Google Scholar 

  14. Tomsick, T. A. et al. Equipoise among recanalization strategies. Neurology 74, 1069–1076 (2010).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Del Zoppo, G. J. et al. Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke. Ann. Neurol. 32, 78–86 (1992).

    Article  CAS  PubMed  Google Scholar 

  16. Riedel, C. H. et al. The importance of size: successful recanalization by intravenous thrombolysis in acute anterior stroke depends on thrombus length. Stroke 42, 1775–1777 (2011).

    Article  PubMed  Google Scholar 

  17. Zeumer, H., Hacke, W., Kolmann, H. L. & Poeck, K. Local fibrinolysis in basilar artery thrombosis (author's transl.) [German]. Dtsch. Med. Wochenschr. 107, 728–731 (1982).

    Article  CAS  PubMed  Google Scholar 

  18. Nogueira, R. G., Yoo, A. J., Buonanno, F. S. & Hirsch, J. A. Endovascular approaches to acute stroke, part 2: a comprehensive review of studies and trials. AJNR Am. J. Neuroradiol. 30, 859–875 (2009).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Furlan, A. et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA 282, 2003–2011 (1999).

    Article  CAS  PubMed  Google Scholar 

  20. Yamaguchi, T. et al. Alteplase at 0.6 mg/kg for acute ischemic stroke within 3 hours of onset: Japan Alteplase Clinical Trial (J-ACT). Stroke 37, 1810–1815 (2006).

    Article  CAS  PubMed  Google Scholar 

  21. Pfefferkorn, T. et al. Drip, ship, and retrieve: cooperative recanalization therapy in acute basilar artery occlusion. Stroke 41, 722–726 (2010).

    Article  PubMed  Google Scholar 

  22. Mishra, N. K. et al. Mismatch-based delayed thrombolysis: a meta-analysis. Stroke 41, e25–e33 (2010).

    PubMed  Google Scholar 

  23. Gulli, G., Khan, S. & Markus, H. S. Vertebrobasilar stenosis predicts high early recurrent stroke risk in posterior circulation stroke and TIA. Stroke 40, 2732–2737 (2009).

    Article  PubMed  Google Scholar 

  24. Hatano, T. et al. Stenting for vertebrobasilar artery stenosis. Acta Neurochir. Suppl. 94, 137–141 (2005).

    Article  CAS  PubMed  Google Scholar 

  25. Qureshi, A. I. et al. Aggressive mechanical clot disruption and low-dose intra-arterial third-generation thrombolytic agent for ischemic stroke: a prospective study. Neurosurgery 51, 1319–1327 (2002).

    Article  PubMed  Google Scholar 

  26. Kerber, C. W., Barr, J. D., Berger, R. M. & Chopko, B. W. Snare retrieval of intracranial thrombus in patients with acute stroke. J. Vasc. Interv. Radiol. 13, 1269–1274 (2002).

    Article  PubMed  Google Scholar 

  27. Wikholm, G. Transarterial embolectomy in acute stroke. AJNR Am. J. Neuroradiol. 24, 892–894 (2003).

    PubMed  PubMed Central  Google Scholar 

  28. Kerber, C. W. et al. Rapid intracranial clot removal with a new device: the alligator retriever. AJNR Am. J. Neuroradiol. 28, 860–863 (2007).

    CAS  PubMed  PubMed Central  Google Scholar 

  29. Hussain, M. S. et al. Mechanical thrombectomy for acute stroke with the alligator retrieval device. Stroke 40, 3784–3788 (2009).

    Article  PubMed  Google Scholar 

  30. Smith, W. S. et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke 36, 1432–1438 (2005).

    Article  PubMed  Google Scholar 

  31. Smith, W. S. et al. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke 39, 1205–1212 (2008).

    Article  PubMed  Google Scholar 

  32. Kim, D. et al. Endovascular mechanical clot retrieval in a broad ischemic stroke cohort. AJNR Am. J. Neuroradiol. 27, 2048–2052 (2006).

    CAS  PubMed  PubMed Central  Google Scholar 

  33. Devlin, T. G., Baxter, B. W., Feintuch, T. A. & Desbiens, N. A. The Merci Retrieval System for acute stroke: the Southeast Regional Stroke Center experience. Neurocrit. Care 6, 11–21 (2007).

    Article  CAS  PubMed  Google Scholar 

  34. Menon, B. K. et al. Initial experience with the Penumbra Stroke System for recanalization of large vessel occlusions in acute ischemic stroke. Neuroradiology 53, 261–266 (2011).

    Article  PubMed  Google Scholar 

  35. Huded, V., Saraf, R. & Limaye, U. Mechanical device the Penumbra system in the management of acute stroke: report of five cases. Neurol. India 57, 310–312 (2009).

    Article  PubMed  Google Scholar 

  36. Struffert, T. et al. Penumbra Stroke System as an 'add-on' for the treatment of large vessel occlusive disease following thrombolysis: first results. Eur. Radiol. 19, 2286–2293 (2009).

    Article  PubMed  Google Scholar 

  37. Kulcsár, Z. et al. Penumbra system: a novel mechanical thrombectomy device for large-vessel occlusions in acute stroke. AJNR Am. J. Neuroradiol. 31, 628–633 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  38. Psychogios, M.-N. et al. Recanalization of large intracranial vessels using the penumbra system: a single-center experience. AJNR Am. J. Neuroradiol. 33, 1488–1493 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  39. Grunwald, I. Q. et al. Revascularization in acute ischaemic stroke using the Penumbra System: the first single center experience. Eur. J. Neurol. 16, 1210–1216 (2009).

    Article  CAS  PubMed  Google Scholar 

  40. Penumbra Pivotal Stroke Trial Investigators. The Penumbra pivotal stroke trial: safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. Stroke 40, 2761–2768 (2009).

  41. Bose, A. et al. The Penumbra System: a mechanical device for the treatment of acute stroke due to thromboembolism. AJNR Am. J. Neuroradiol. 29, 1409–1413 (2008).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Nogueira, R. G. et al. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet 380, 1231–1240 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  43. Saver, J. L. et al. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet 380, 1241–1249 (2012).

    Article  PubMed  Google Scholar 

  44. Costalat, V. et al. Prognostic factors related to clinical outcome following thrombectomy in ischemic stroke (RECOST study). 50 patients prospective study. Eur. J. Radiol. 81, 4075–4082 (2012).

    Article  CAS  PubMed  Google Scholar 

  45. Stampfl, S. et al. Stent placement for flow restoration in acute ischemic stroke: a single-center experience with the Solitaire stent system. AJNR Am. J. Neuroradiol. 32, 1245–1248 (2011).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. Rohde, S. et al. Mechanical thrombectomy in acute embolic stroke: preliminary results with the Revive device. Stroke 42, 2954–2956 (2011).

    Article  PubMed  Google Scholar 

  47. Brekenfeld, C. et al. Impact of retrievable stents on acute ischemic stroke treatment. AJNR Am. J. Neuroradiol. 32, 1269–1273 (2011).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  48. Cohen, J. E. et al. Preliminary experience with the use of self-expanding stent as a thrombectomy device in ischemic stroke. Neurol. Res. 33, 214–219 (2011).

    Article  PubMed  Google Scholar 

  49. Miteff, F. et al. Mechanical thrombectomy with a self-expanding retrievable intracranial stent (Solitaire AB): experience in 26 patients with acute cerebral artery occlusion. AJNR Am. J. Neuroradiol. 32, 1078–1081 (2011).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Park, H. et al. A retrieval thrombectomy technique with the Solitaire stent in a large cerebral artery occlusion. Acta Neurochir. (Wien) 153, 1625–1631 (2011).

    Article  Google Scholar 

  51. Roth, C. et al. Stent-assisted mechanical recanalization for treatment of acute intracerebral artery occlusions. Stroke 41, 2559–2567 (2010).

    Article  CAS  PubMed  Google Scholar 

  52. Castaño, C. et al. Mechanical thrombectomy with the Solitaire AB device in large artery occlusions of the anterior circulation: a pilot study. Stroke 41, 1836–1840 (2010).

    Article  PubMed  Google Scholar 

  53. Dorn, F., Stehle, S., Lockau, H., Zimmer, C. & Liebig, T. Endovascular treatment of acute intracerebral artery occlusions with the solitaire stent: single-centre experience with 108 recanalization procedures. Cerebrovasc. Dis. 34, 70–77 (2012).

    Article  CAS  PubMed  Google Scholar 

  54. Mokin, M. et al. Solitaire flow restoration thrombectomy for acute ischemic stroke: retrospective multicenter analysis of early postmarket experience after FDA approval. Neurosurgery 73, 19–25 (2013).

    Article  PubMed  Google Scholar 

  55. de Castro-Afonso, L. H. et al. Mechanical thrombectomy with solitaire stent retrieval for acute ischemic stroke in a Brazilian population. Clinics (Sao Paulo) 67, 1379–1386 (2012).

    Article  Google Scholar 

  56. Mendonça, N. et al. Trevo System: single-center experience with a novel mechanical thrombectomy device. J. Neuroimaging 23, 7–11 (2013).

    Article  PubMed  Google Scholar 

  57. San Román, L. et al. Single-center experience of cerebral artery thrombectomy using the TREVO device in 60 patients with acute ischemic stroke. Stroke 43, 1657–1659 (2012).

    Article  PubMed  Google Scholar 

  58. Jansen, O. et al. Neurothrombectomy for the treatment of acute ischemic stroke: results from the TREVO study. Cerebrovasc. Dis. (in press).

  59. Dávalos, A. et al. Retrospective multicenter study of Solitaire FR for revascularization in the treatment of acute ischemic stroke. Stroke 43, 2699–2705 (2012).

    Article  PubMed  Google Scholar 

  60. Machi, P. et al. Solitaire FR thrombectomy system: immediate results in 56 consecutive acute ischemic stroke patients. J. Neurointerv. Surg. 4, 62–66 (2012).

    Article  PubMed  Google Scholar 

  61. Broderick, J. P. et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N. Engl. J. Med. 368, 893–903 (2013).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  62. Rha, J.-H. & Saver, J. L. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 38, 967–973 (2007).

    Article  PubMed  Google Scholar 

  63. Saver, J. L. Time is brain—quantified. Stroke 37, 263–266 (2006).

    Article  PubMed  Google Scholar 

  64. Broderick, J. P. Devices and clinical trials: overview and equipoise. Stroke 44, S3–S6 (2013).

    Article  PubMed  Google Scholar 

  65. Goyal, M. et al. Effect of baseline CT scan appearance and time to recanalization on clinical outcomes in endovascular thrombectomy of acute ischemic strokes. Stroke 42, 93–97 (2011).

    Article  PubMed  Google Scholar 

  66. Jansen, O., Schellinger, P., Fiebach, J., Hacke, W. & Sartor, K. Early recanalisation in acute ischaemic stroke saves tissue at risk defined by MRI. Lancet 353, 2036–2037 (1999).

    Article  CAS  PubMed  Google Scholar 

  67. Kidwell, C. S. et al. A trial of imaging selection and endovascular treatment for ischemic stroke. N. Engl. J. Med. 368, 914–923 (2013).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  68. Albers, G. W. Impact of recanalization, reperfusion, and collateral flow on clinical efficacy. Stroke 44, S11–S12 (2013).

    Article  PubMed  Google Scholar 

  69. Wheeler, H. M. et al. Early diffusion-weighted imaging and perfusion-weighted imaging lesion volumes forecast final infarct size in DEFUSE 2. Stroke 44, 681–685 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  70. Lansberg, M. G. & Albers, G. W. Selection of patients for intra-arterial therapy—authors' reply. Lancet Neurol. 12, 225–226 (2013).

    Article  PubMed  Google Scholar 

  71. Riedel, C. H., Zoubie, J., Ulmer, S., Gierthmuehlen, J. & Jansen, O. Thin-slice reconstructions of nonenhanced CT images allow for detection of thrombus in acute stroke. Stroke 43, 2319–2323 (2012).

    Article  PubMed  Google Scholar 

  72. US National Library of Medicine. ClinicalTrials.gov [online], (2013).

  73. US National Library of Medicine. ClinicalTrials.gov [online], (2013).

  74. Berlis, A. et al. Mechanical thrombolysis in acute ischemic stroke with endovascular photoacoustic recanalization. 35, 1112–1116 (2004).

  75. US National Library of Medicine. ClinicalTrials.gov [online], (2012).

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  1. Institute of Neuroradiology, University Clinic Kiel, Arnold-Heller-Strasse 3, Kiel, 24105, Germany

    Olav Jansen & Axel Rohr

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Both authors researched data for the article, and made substantial contributions to discussion of the content, writing the article, and to review and/or editing of the manuscript before submission.

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Jansen, O., Rohr, A. Neurothrombectomy in the treatment of acute ischaemic stroke. Nat Rev Neurol 9, 645–652 (2013). https://doi.org/10.1038/nrneurol.2013.204

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