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Table of Contents    
Year : 2014  |  Volume : 62  |  Issue : 3  |  Page : 237-238

Endovascular treatment in acute ischemic stroke: Where it stands?

Chief of Neurology, The Institute of Neurological Sciences, CARE Hospital, Banjara Hills, Hyderabad, Andhra Pradesh, India

Date of Submission03-Feb-2014
Date of Decision03-Feb-2014
Date of Acceptance03-Feb-2014
Date of Web Publication18-Jul-2014

Correspondence Address:
J. M. K. Murthy
Chief of Neurology, The Institute of Neurological Sciences, CARE Hospital, Banjara Hills, Hyderabad - 500 034, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.136892

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How to cite this article:
Murthy J. Endovascular treatment in acute ischemic stroke: Where it stands?. Neurol India 2014;62:237-8

How to cite this URL:
Murthy J. Endovascular treatment in acute ischemic stroke: Where it stands?. Neurol India [serial online] 2014 [cited 2021 Jan 16];62:237-8. Available from:

Early recanalization within 4.5 h is the proven treatment in acute ischemic stroke. Data from randomized clinical trials have established the clinical efficacy of intravenous tissue plasminogen activator (IV tPA) for carefully selected patients with acute ischemic stroke when administered within 4.5 h of onset. [1],[2],[3],[4] However, the outcome is poor for patients with large artery-occlusion even when administrated within the 4.5-h window. [1],[5],[6] Rescue endovascular treatment may be an alternate approach to recanalization in patients with large-artery occlusion who have not responded to IV tPA. This approach may minimize or obviate the use of chemical thrombolytics, thereby decreasing the risk of intracerebral hemorrhage.

The recent endovascular treatment trials in acute ischemic stroke: Interventional Management of Stroke (IMS) III, [7] Magnetic Resonance and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE), [8] and SYNTHESIS EXPANSION [9] have not shown a large magnitude benefit of endovascular treatment over IV tPA alone in IV tPA-eligible patients, even in patients with persistent large-artery occlusion. These trials have also not demonstrated endovascular treatment superior to IV tPA in ineligible patients because they exceeded the window period (>4.5 h). Rates of intracerebral hemorrhages were similar between IV tPA and endovascular treatment. [7],[9]

Various mechanical clot retrieval devices used in various trials include MERCI retriever (Concentric Medical), Penumbra System (Penumbra), Solitaire (Covidien), and Trevo (Concentric/Stryker) stent retrievers. In recent literature review, MERCI retriever has been shown to be safe, with recanalization rate of 63.6%, 90-day mRS ≤2 of 32.0%, and 90-day mortality of 35.2%. [10] The Penumbra Pivotal Stroke trial showed that Penumbra device is safe, with recanalization rate of 82%, 90-day mRS ≤R2 of 25%, and 90-day mortality of 32.8%. [11]

Stent retrievers Solitaire (Covidien) and Trevo (Concentric/Stryker) have been introduced recently. No significant differences were found in the rate of recanalization rates between the two devices. [12] A systemic review of the use of Solitaire stent retriever in patients with ischemic stroke showed the safety of the device with a recanalization rate of 89.7% and a favorable outcome of mRS <2 of 47%, and the recanalization rates were superior to MERCI device. However, the study cohort includes a heterogeneous and non-randomized sample. [13] In the Solitaire With the Intention For Thrombectomy (SWIFT) trial the recanalization rate with Solitaire stent retriever was superior to MERCI device (61% vs. 24%) and more patients had a more favorable outcome in the Solitaire group (58% vs. 33%). [14] TERVO 2 trial has shown superior recanalization rates (86% vs. 60%) and a more favorable outcome (44% vs. 22%) with TERVO stent retriever as compared to MERCI device. [15] In this issue of Neurology India, Huded et al., [16] (2014) reported their experience of endovascular treatment in 45 patients with moderate acute ischemic stroke due to large-artery occlusion who either had contraindication to IV tPA or who failed IV tPA. Solitaire stent retrieval was used in 33 patients. The recanalization rate was 71% similar to the other endovascular treatment trials, whereas 90-day mRS ≤2 was 64% which is much superior to other endovascular treatment trials. The authors attributed this positive effect to the young age of the study cohort. It is not certain whether young age alone explains this superiority and to prove this hypothesis, one needs a well-designed study.

The devises used in IMS III, [7] MR RESCUE [8] and SYNTHESIS EXPANSION, [9] trials were mainly MERCI retrievers (Concentric Medical) or Penumbra System (Penumbra). In a small proportion of patients in IMS III trial [7] and in SYNTHESIS EXPANSION trial, [9] Solitaire (Covidien) and Trevo (Concentric/Stryker) stent retrievers were used, respectively. As discussed earlier, recanalization rates are superior with Solitaire and Trevo stent retrievers compared to MERCI or Penumbra system. However, this better recanalization has not translated much into higher good functional outcomes.

From the review of various endovascular treatment trials, the place of endovascular treatment in patients with large-artery occlusion is uncertain over IV tPA alone in IV tPA-eligible patients. Similar findings in patients were made in ineligible patients because they exceeded the window period for IV tPA. Till such time when we have good data to show the efficacy of endovascular treatment, one should be cautious to institute endovascular treatment in these select groups of patients.

  References Top

1.Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Study Group. N Engl J Med 1995;333:1581-7.  Back to cited text no. 1
2.Lees KR, Bluhmki E, von Kummer R, Brott TG, Toni D, Grotta JC, et al. ECASS, ATLANTIS, NINDS and EPITHET rt-PA Study Group. Time to treatment with intravenous alteplase and outcome in stroke: An updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 2010;375:1695-703.  Back to cited text no. 2
3.Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, et al. ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008;359:1317-29.  Back to cited text no. 3 Los Ríos la Rosa F, Khoury J, Kissela BM, Kissela BM, Flaherty ML, Alwell K, et al. Eligibility for intravenous recombinant tissue-type plasminogen activator within a population: The effect of the European Cooperative Acute Stroke Study (ECASS) III Trial. Stroke 2012;43:1591-5.  Back to cited text no. 4
5.Fink JN, Selim MH, Kumar S, Silver B, Linfante I, Caplan LR, et al. Is the association of National Institutes of Health Stroke Scale scores and acute magnetic resonance imaging stroke volume equal for patients with right- and left-hemisphericischemic stroke? Stroke 2002;33:954-8.  Back to cited text no. 5
6.Bhatia R, Hill MD, Shoba N, Menon B, Bal S, Kochar P, et al. Low rates of recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: Real-world experience and a call for action. Stroke 2010;41:2254-8.  Back to cited text no. 6
7.Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, et al. Interventional Management of Stroke (IMS) III Investigators. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 2013;368:893-903.  Back to cited text no. 7
8.Ciccone A, Valvassori L, Nichelatti M, Sgoifo A, Ponzio M, Sterzi R, et al. SYNTHESIS Expansion Investigators. Endovascular treatment for acute ischemic stroke. N Engl J Med 2013;368:904-13.  Back to cited text no. 8
9.Kidwell CS, Jahan R, Gornbein J, Alger JR, Nenov V, Ajani Z, et al. MR RESCUE Investigators. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 2013;368:914-23.  Back to cited text no. 9
10.Alshekhlee A, Pandya DJ, English J, Zaidat OO, Mueller N, Gupta R, et al. Merci mechanical thrombectomy retriever for acute ischemic stroke therapy: Literature review. Neurology 2012;79:S126-34.  Back to cited text no. 10
11.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 2009;40:2761-68.  Back to cited text no. 11
12.Mendonça N, Flores A, Pagola J, Rubiera M, Rodríguez-Luna D, De Miquel MA, et al. Trevo versus Solitaire a head-to-head comparison between two heavy weights of clot retrieval. J Am Soc Neuroimaging 2014;24:167-70.  Back to cited text no. 12
13.Koh JS, Lee SJ, Ryu CW, Kim HS. Safety and efficacy of mechanical thrombectomy with solitaire stent retrieval for acute ischemic stroke: A systematic review. Neurointervention 2012;7:1-9.  Back to cited text no. 13
14.Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, et al. SWIFT Trialists. Solitaire flow restoration device versus the Merci retriever in patients with acute ischemic stroke (SWIFT): A randomised, parallel-group, non-inferiority trial. Lancet 2012;380:1241-9.  Back to cited text no. 14
15.Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA, et al. TREVO 2 Trialists. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): A randomised trial. Lancet 2012;380:1231-40.  Back to cited text no. 15
16.Huded V, Nair RR, de Souza R, Vyas DD. Endovascular treatment of acute ischemic stroke: An Indian experience from a tertiary care centre. Neurol India 2014.  Back to cited text no. 16


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