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Update on Large-Vessel Revascularization in Acute Ischemic Stroke

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Abstract

Purpose of review

This review presents the critical appraisal of current therapeutic strategies for patients with large-vessel occlusion (LVO) acute ischemic stroke (AIS). We provide the reader with most recent evidence supporting endovascular thrombectomy (EVT), different techniques used for thrombectomy, and highlight knowledge gaps regarding therapeutic efficacy of this intervention in respective subgroup of these patients based on site of occlusion, size of ischemic core, time from symptom onset, utility of concurrent intravenous thrombolysis (IVT), mild strokes, or tandem occlusions.

Recent findings

EVT is the established standard of care for patients with moderate-severe LVO-AIS presenting within 24 h of symptom onset and favorable perfusion imaging irrespective of IVT. The DIRECT-MT and SKIP randomized clinical trials (RCT) established that EVT without IVT for eligible patients is not non-inferior to concurrent IVT. The RESCUE-Japan LIMIT randomized controlled trial showed EVT in patients with ASPECTS score of 3–5 presenting within 6 h of symptom onset or within 24 h if no early ischemic change was seen on MRI FLAIR sequence. Good functional outcome at 90 days (mRS 0–3) was seen in 31% patients undergoing EVT and only in 12.7% in the medical group (relative risk 2.43, 95%CI 1.35–4.37, p = 0.002). Any ICH was notably higher in the EVT group (58% versus 31.4%, p < 0.001). The SELECT-2 RCT enrolled patients with CT ASPECTS of 3–5, or CT or MR perfusion core > 50 cc. The mRS scores moved toward functionally independent survival, with a generalized odds ratio favoring thrombectomy of 1.51 (95% CI 1.20–1.89; p < 0.001). In addition, a phase 2b, randomized, placebo-controlled clinical trial, CHOICE, showed that intraarterial administration of alteplase (0.225 mg/kg; maximum dose 22.5 mg) after successful EVT (TICI 2b–3) led to 18.6% increase (adjusted risk difference) in excellent functional outcomes at 90 days (59% versus 40.4%, 95% CI 0.3–36.4%, p = 0.047).

Summary

The industry has kept pace with the evolving needs and optimizing devices to achieve desired procedural efficacy for EVT resulting in great functional outcomes. We continue to explore the means to expand the indication and eligibility of patients suffering from LVO-AIS who would benefit from this life-saving procedure.

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Papers of particular interest, published recently, have been highlighted as: • Of importance

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Authors and Affiliations

  1. Department of Radiology and Neurosurgery, Mount Sinai Medical Center, Miami Beach, FL, USA

    Vasu Saini MD

  2. Department of Neurology and Radiology, New York University Langone Medical Center, New York, NY, USA

    Vera Sharashidze MD

  3. Department of Neurosurgery, University of Louisville, Louisville, KY, USA

    Isaac Josh Abecassis MD

  4. Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Luis Guada MD

  5. Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA

    Jude Hassan Charles MD & Dileep R. Yavagal MD

  6. Department of Neurology, Neurosurgery and Radiology, Indiana University School of Medicine, Indianapolis, IN, USA

    Kaustubh Limaye MD

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Vasu Saini declares that he has no conflict of interest. Vera Sharashidze declares that she has no conflict of interest. Luis Guada declares that he has no conflict of interest. Kaustubh Limaye declares that he has no conflict of interest. Isaac Josh Abecassis is a consultant for IschemaView (Rapid) Inc. Consultant and equity in Remedy Robotics. Dileep R. Yavagal is a consultant for Cerenovus, DeckTherapeutics, GLG Consulting, Guidepoint Consulting, Mosaic Consulting, Neuralanalytics, Medtronic, Vascular Dynamics, and Poseydon Medical LLC; speaker and member of clinical trial steering committee for SWIFT-Prime–RAPID; consultant and member of clinical trial steering committee for the TIGER and CALM2; and consultant for Athersys Inc. and clinical trial steering committee member for MASTERS2.

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Saini, V., Sharashidze, V., Abecassis, I.J. et al. Update on Large-Vessel Revascularization in Acute Ischemic Stroke. Curr Treat Options Neurol 25, 241–259 (2023). https://doi.org/10.1007/s11940-023-00758-3

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