Evolution of endovascular mechanical thrombectomy for acute ischemic stroke

Abstract

Acute ischemic stroke (AIS) is a common medical problem associated with significant morbidity and mortality worldwide. A small proportion of AIS patients meet eligibility criteria for intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator, and its efficacy for large vessel occlusion is poor. Therefore, an increasing number of patients with AIS are being treated with endovascular mechanical thrombectomy when IVT is ineffective or contraindicated. Rapid advancement in catheter-based and endovascular device technology has led to significant improvements in rates of cerebral reperfusion with these devices. Stentrievers and modern aspiration catheters have now surpassed earlier generation devices in the degree and rapidity of revascularization. This progress has been achieved with no concurrent increase in risk of major complications or mortality, both when used alone or in combination with IVT. The initial randomized controlled trials comparing endovascular therapy to IVT for AIS failed to show superior outcomes with endovascular treatment, but key limitations of each trial may limit the significance of these results to current practice. While endovascular devices and operator experience continue to evolve, we are optimistic that this will be accompanied by improvements in patient outcomes. This review highlights the major endovascular devices used in current practice and the trials which have investigated their efficacy.

Keywords: Cerebral infarction; Endovascular procedures; Intracranial hemorrhages; Stents; Stroke

Core tip: This review discusses the critical advancements in endovascular device technology for the treatment of acute ischemic stroke. Endovascular mechanical thrombectomy is becoming an increasingly utilized treatment approach for patients in whom intravenous thrombolysis with recombinant tissue plasminogen activator is ineffective or contraindicated. While three recent randomized controlled trials found no benefit of endovascular thrombectomy over intravenous therapy, it is important for clinicians to understand the limitations of these trials and recognize the expected key role of endovascular therapy in the future management of stroke patients.