Skip to main content

Advertisement

Log in

Endovascular Interventions in Acute Ischemic Stroke: Recent Evidence, Current Challenges, and Future Prospects

  • Clinical Trials and Their Interpretations (J. Kizer, Section Editor)
  • Published:
Current Atherosclerosis Reports Aims and scope Submit manuscript

An Erratum to this article was published on 27 July 2016

Abstract

After many years of clinical research, endovascular thrombectomy has been conclusively proven to be an effective treatment in acute ischemic stroke. The evidence is compelling; however, it is generated in high volume stroke centers with stroke expertise. Challenges remain ahead on translating and implementing this evidence in routine clinical care across the world. The current evidence has opened up avenues for further research and innovation in this field. In this review, we will discuss the evolution of evidence on endovascular thrombectomy followed by a discussion of challenges and future prospects in this exciting field of stroke care.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others

References

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

  1. Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372(1):11–20.

    Article  PubMed  Google Scholar 

  2. Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009–18.

    Article  CAS  PubMed  Google Scholar 

  3. Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019–30.

    Article  CAS  PubMed  Google Scholar 

  4. Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 h after symptom onset in ischemic stroke. N Engl J Med. 2015;372(24):2296–306.

    Article  CAS  PubMed  Google Scholar 

  5. Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):2285–95.

    Article  CAS  PubMed  Google Scholar 

  6. Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016. Recent individual patient level metaanalysis of the 5 RCT’s published by the HERMES collaboration.

  7. Lewandowski CA, Frankel M, Tomsick TA, et al. Combined intravenous and intra-arterial r-TPA versus intra-arterial therapy of acute ischemic stroke: Emergency Management of Stroke (EMS) bridging trial. Stroke; J Cereb Circ. 1999;30(12):2598–605.

    Article  CAS  Google Scholar 

  8. Investigators IMSS. Combined intravenous and intra-arterial recanalization for acute ischemic stroke: the Interventional Management of Stroke Study. Stroke; J Cereb Circ. 2004;35(4):904–11.

    Article  Google Scholar 

  9. Investigators IIT. The Interventional Management of Stroke (IMS) II Study. Stroke; J Cereb Circ. 2007;38(7):2127–35.

    Article  Google Scholar 

  10. Smith WS, Sung G, Starkman S, et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke; J Cereb Circ. 2005;36(7):1432–8.

    Article  Google Scholar 

  11. Smith WS, Sung G, Saver J, et al. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke; J Cereb Circ. 2008;39(4):1205–12.

    Article  Google Scholar 

  12. Penumbra Pivotal Stroke Trial I. 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; J Cereb Circ. 2009;40(8):2761–8.

    Article  Google Scholar 

  13. Kidwell CS, Jahan R, Gornbein J, et al. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med. 2013;368(10):914–23.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Ciccone A, Valvassori L, Nichelatti M, et al. Endovascular treatment for acute ischemic stroke. N Engl J Med. 2013;368(10):904–13.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Broderick JP, Palesch YY, Demchuk AM, et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med. 2013;368(10):893–903.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Khatri P, Yeatts SD, Mazighi M, et al. Time to angiographic reperfusion and clinical outcome after acute ischaemic stroke: an analysis of data from the Interventional Management of Stroke (IMS III) phase 3 trial. Lancet Neurol. 2014;13(6):567–74.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Menon BK, Almekhlafi MA, Pereira VM, et al. Optimal workflow and process-based performance measures for endovascular therapy in acute ischemic stroke: analysis of the Solitaire FR thrombectomy for acute revascularization study. Stroke; J Cereb Circ. 2014;45(7):2024–9.

    Article  Google Scholar 

  18. Nambiar V, Sohn SI, Almekhlafi MA, et al. CTA collateral status and response to recanalization in patients with acute ischemic stroke. AJNR Am J Neuroradiol. 2014;35(5):884–90.

    Article  CAS  PubMed  Google Scholar 

  19. Almekhlafi MA, Hockley A, Desai JA, et al. Overcoming the evening/weekend effects on time delays and outcomes of endovascular stroke therapy: the Calgary Stroke Program experience. J Neurointerventional Surg. 2014;6(10):729–32.

    Article  Google Scholar 

  20. Hill MD, Demchuk AM, Goyal M, et al. Alberta Stroke Program early computed tomography score to select patients for endovascular treatment: Interventional Management of Stroke (IMS)-III Trial. Stroke; J Cereb Circ. 2014;45(2):444–9.

    Article  Google Scholar 

  21. Gupta R, Vora NA, Horowitz MB, et al. Multimodal reperfusion therapy for acute ischemic stroke: factors predicting vessel recanalization. Stroke; J Cereb Circ. 2006;37(4):986–90.

    Article  Google Scholar 

  22. Levy EI, Ecker RD, Horowitz MB, et al. Stent-assisted intracranial recanalization for acute stroke: early results. Neurosurgery. 2006;58(3):458–63.

  23. Saver JL, Jahan R, Levy EI, 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. 2012;380(9849):1241–9.

    Article  PubMed  Google Scholar 

  24. Nogueira RG, Lutsep HL, Gupta R, et al. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet. 2012;380(9849):1231–40.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Brandler ES, Sharma M, Sinert RH, Levine SR. Prehospital stroke scales in urban environments: a systematic review. Neurology. 2014;82(24):2241–9.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Nakae T, Kataoka H, Kuwata S, Iihara K. Smartphone-assisted prehospital medical information system for analyzing data on prehospital stroke care. Stroke; J Cereb Circ. 2014;45(5):1501–4.

    Article  Google Scholar 

  27. Yperzeele L, Van Hooff RJ, De Smedt A, et al. Prehospital stroke care: limitations of current interventions and focus on new developments. Cerebrovasc Dis. 2014;38(1):1–9.

    Article  CAS  PubMed  Google Scholar 

  28. Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet. 2000;355(9216):1670–4.

    Article  CAS  PubMed  Google Scholar 

  29. Alberta Stroke Program Early CT score (ASPECTS) [cited 2016 Mar 07]. Available from: https://aspectsinstroke.com/aspectsinstroke.com.

  30. Yoo AJ, Zaidat OO, Chaudhry ZA, et al. Impact of pretreatment noncontrast CT Alberta Stroke Program Early CT Score on clinical outcome after intra-arterial stroke therapy. Stroke; J Cereb Circ. 2014;45(3):746–51.

    Article  CAS  Google Scholar 

  31. Hill MD, Demchuk AM, Tomsick TA, Palesch YY, Broderick JP. Using the baseline CT scan to select acute stroke patients for IV-IA therapy. AJNR Am J Neuroradiol. 2006;27(8):1612–6.

    CAS  PubMed  Google Scholar 

  32. Hill MD, Rowley HA, Adler F, et al. Selection of acute ischemic stroke patients for intra-arterial thrombolysis with pro-urokinase by using ASPECTS. Stroke; J Cereb Circ. 2003;34(8):1925–31.

    Article  Google Scholar 

  33. Menon BK, Puetz V, Kochar P, Demchuk AM. ASPECTS and other neuroimaging scores in the triage and prediction of outcome in acute stroke patients. Neuroimaging Clin N Am. 2011;21(2):407–23. xii.

    Article  PubMed  Google Scholar 

  34. Demchuk AM, Goyal M, Yeatts SD, et al. Recanalization and clinical outcome of occlusion sites at baseline CT angiography in the Interventional Management of Stroke III trial. Radiology. 2014;273(1):202–10.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Mishra SM, Dykeman J, Sajobi TT, et al. Early reperfusion rates with IV tPA are determined by CTA clot characteristics. AJNR Am J Neuroradiol. 2014;35(12):2265–72.

    Article  CAS  PubMed  Google Scholar 

  36. Liebeskind DS. Collaterals in acute stroke: beyond the clot. Neuroimaging Clin N Am. 2005;15(3):553–73. x.

    Article  PubMed  Google Scholar 

  37. Liebeskind DS, Tomsick TA, Foster LD, et al. Collaterals at angiography and outcomes in the Interventional Management of Stroke (IMS) III trial. Stroke; J Cereb Circ. 2014;45(3):759–64.

    Article  CAS  Google Scholar 

  38. Campbell BC, Christensen S, Levi CR, et al. Cerebral blood flow is the optimal CT perfusion parameter for assessing infarct core. Stroke; J Cereb Circ. 2011;42(12):3435–40.

    Article  Google Scholar 

  39. d’Esterre CD, Boesen ME, Ahn SH, et al. Time-dependent computed tomographic perfusion thresholds for patients with acute ischemic stroke. Stroke; J Cereb Circ. 2015;46(12):3390–7. The work highlights new understanding of the CT perfusion thresholds in acute ischemic stroke.

    Article  Google Scholar 

  40. Goyal M, Almekhlafi MA, Fan L, et al. Evaluation of interval times from onset to reperfusion in patients undergoing endovascular therapy in the Interventional Management of Stroke III trial. Circulation. 2014;130(3):265–72.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Mocco J, Fargen KM, Goyal M, et al. Neurothrombectomy trial results: stroke systems, not just devices, make the difference. Int J Stroke: Off J Int Stroke Soc. 2015;10(7):990–3.

    Article  CAS  Google Scholar 

  42. Adams Jr HP, Biller J. Future of subspecialty training in vascular neurology. Stroke; J Cereb Circ. 2014;45(12):3730–3.

    Article  Google Scholar 

  43. Leira EC, Kaskie B, Froehler MT, Adams Jr HP. The growing shortage of vascular neurologists in the era of health reform: planning is brain! Stroke; J Cereb Circ. 2013;44(3):822–7.

    Article  Google Scholar 

  44. Zaidat OO, Lazzaro M, McGinley E, et al. Demand–supply of neurointerventionalists for endovascular ischemic stroke therapy. Neurology. 2012;79(13 Suppl 1):S35–41.

    Article  PubMed  Google Scholar 

  45. Lavine SD, Cockroft K, Hoh B, et al. Training guidelines for endovascular ischemic stroke intervention: an international multi-society consensus document. AJNR Am J Neuroradiol. 2016. These are international expert group recommendations for endovascular stroke intervention training and skill maintance.

  46. Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet. 2014;384(9958):1929–35.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in acute cerebral thromboembolism. JAMA: J Am Med Assoc. 1999;282(21):2003–11.

    Article  CAS  Google Scholar 

  48. Alexandrov AV, Molina CA, Grotta JC, et al. Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke. N Engl J Med. 2004;351(21):2170–8.

    Article  CAS  PubMed  Google Scholar 

  49. Menon BK, Campbell BC, Levi C, Goyal M. Role of imaging in current acute ischemic stroke workflow for endovascular therapy. Stroke; J Cereb Circ. 2015;46(6):1453–61. This highlights the role of advanced imaging in patient selection for endovascular intervention.

    Article  CAS  Google Scholar 

  50. Powers WJ, Derdeyn CP, Biller J, et al. 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke; J Cereb Circ. 2015;46(10):3020–35.

    Article  CAS  Google Scholar 

  51. Casaubon LK, Boulanger JM, Blacquiere D, et al. Canadian stroke best practice recommendations: hyperacute stroke care guidelines, update 2015. Int J Stroke: Off J Int Stroke Soc. 2015;10(6):924–40.

    Article  Google Scholar 

  52. Saqqur M, Uchino K, Demchuk AM, et al. Site of arterial occlusion identified by transcranial Doppler predicts the response to intravenous thrombolysis for stroke. Stroke; J Cereb Circ. 2007;38(3):948–54.

    Article  Google Scholar 

  53. del Zoppo GJ, Poeck K, Pessin MS, et al. Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke. Ann Neurol. 1992;32(1):78–86.

    Article  PubMed  Google Scholar 

  54. Bhatia R, Shobha N, Menon BK, et al. Combined full-dose IV and endovascular thrombolysis in acute ischaemic stroke. Int J Stroke: Off J Int Stroke Soc. 2014;9(8):974–9.

    Article  Google Scholar 

  55. Lemarchant S, Docagne F, Emery E, Vivien D, Ali C, Rubio M. tPA in the injured central nervous system: different scenarios starring the same actor? Neuropharmacology. 2012;62(2):749–56.

    Article  CAS  PubMed  Google Scholar 

  56. Yepes M, Roussel BD, Ali C, Vivien D. Tissue-type plasminogen activator in the ischemic brain: more than a thrombolytic. Trends Neurosci. 2009;32(1):48–55.

    Article  CAS  PubMed  Google Scholar 

  57. Kirkman MA, Lambden S, Smith M. Challenges in the anesthetic and intensive care management of acute ischemic stroke. J Neurosurg Anesthesiol 2015. 11 Sep 2015.

  58. Brinjikji W, Murad MH, Rabinstein AA, Cloft HJ, Lanzino G, Kallmes DF. Conscious sedation versus general anesthesia during endovascular acute ischemic stroke treatment: a systematic review and meta-analysis. AJNR Am J Neuroradiol. 2015;36(3):525–9.

    Article  CAS  PubMed  Google Scholar 

  59. Schonenberger S, Mohlenbruch M, Pfaff J, et al. Sedation vs. Intubation for Endovascular Stroke TreAtment (SIESTA)—a randomized monocentric trial. Int J Stroke: Off J Int Stroke Soc. 2015;10(6):969–78.

    Article  Google Scholar 

  60. Sedation versus general anesthesia for endovascular therapy in acute stroke—impact on neurological outcome (ANSTROKE). In: ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2000 [cited 2015 Dec 17]. Available from: https://clinicaltrials.gov/ct2/show/NCT01872884.

  61. “GOLIATH”—General Or Local Anaestesia in Intra Arterial THerapy. In: ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2000 [cited 2015 Dec 17]. Available from: https://clinicaltrials.gov/ct2/show/NCT02317237.

  62. Steglich-Arnholm H, Holtmannspotter M, Kondziella D, et al. Thrombectomy assisted by carotid stenting in acute ischemic stroke management: benefits and harms. J Neurol. 2015;262(12):2668–75.

    Article  CAS  PubMed  Google Scholar 

  63. Han Z, Liu X, Luo Y, Ji X. Therapeutic hypothermia for stroke: where to go? Exp Neurol. 2015;272:67–77.

    Article  PubMed  Google Scholar 

  64. Herson PS, Traystman RJ. Animal models of stroke: translational potential at present and in 2050. Future Neurol. 2014;9(5):541–51.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  65. Hill MD, Martin RH, Mikulis D, et al. Safety and efficacy of NA-1 in patients with iatrogenic stroke after endovascular aneurysm repair (ENACT): a phase 2, randomised, double-blind, placebo-controlled trial. Lancet Neurol. 2012;11(11):942–50.

    Article  CAS  PubMed  Google Scholar 

  66. Saver JL, Starkman S, Eckstein M, et al. Prehospital use of magnesium sulfate as neuroprotection in acute stroke. N Engl J Med. 2015;372(6):528–36.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Mayank Goyal.

Ethics declarations

Conflict of Interest

Ramana Appireddy and Charlotte Zerna declare that they have no conflict of interest.

Bijoy K. Menon declares grant support from the Canadian Institute of Health Research and from the Heart and Stroke Foundation/University of Calgary (professorship). Dr. Menon also declares a board membership with Quikflo Health Inc., and a patent pending on Systems of Triage in Stroke.

Mayank Goyal declares grant support from Covidien, consulting fees from Medtronic and Stryker, and grant support from GE Healthcare.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Clinical Trials and Their Interpretations

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Appireddy, R., Zerna, C., Menon, B.K. et al. Endovascular Interventions in Acute Ischemic Stroke: Recent Evidence, Current Challenges, and Future Prospects. Curr Atheroscler Rep 18, 40 (2016). https://doi.org/10.1007/s11883-016-0588-z

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11883-016-0588-z

Keywords

Navigation