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Table of Contents    
COMMENTARY
Year : 2021  |  Volume : 69  |  Issue : 2  |  Page : 383-384

Stentriever Thrombectomy for Acute Ischemic Stroke


Department of Neuro-Vascular Interventions, Breach Candy Hospital, Mumbai, Maharashtra, India

Date of Submission22-Mar-2021
Date of Decision22-Mar-2021
Date of Acceptance22-Mar-2021
Date of Web Publication24-Apr-2021

Correspondence Address:
Anil Pandurang Karapurkar
Department of Neuro.Vascular Interventions, Breach Candy Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.314555

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How to cite this article:
Karapurkar AP, Deshmukh ND, Singh RK. Stentriever Thrombectomy for Acute Ischemic Stroke. Neurol India 2021;69:383-4

How to cite this URL:
Karapurkar AP, Deshmukh ND, Singh RK. Stentriever Thrombectomy for Acute Ischemic Stroke. Neurol India [serial online] 2021 [cited 2021 May 14];69:383-4. Available from: https://www.neurologyindia.com/text.asp?2021/69/2/383/314555




Intravenous thrombolysis has been one of the revolutions in the management of acute ischemic stroke (AIS). It improved the outcome and quality of life of patients. Intravenous thrombolysis has been approved till 3 and 4.5 hours after the onset of stroke. Mechanical thrombectomy has been shown to have better recanalization rates compared to standard medical management in acute ischemic strokes with large vessel occlusion (LVO). Earlier used devices include Merci (2004), Penumbra (2009), Stent retrievers (early 2012), Solumbra (late 2012) and Adapt (2013). Currently, aspiration with large-bore catheters and stentrievers are the accepted techniques for recanalization.

The authors (NI_803_18) have compared the safety and efficacy of Solitaire and Trevo stents for endovascular treatment of acute ischemic stroke. This was a single-centre, retrospective, registry-based study. They evaluated 130 patients who had symptoms within 24 hours, who underwent EVT either with Solitaire or Trevo. 79 patients were treated with Solitaire and 51 with Trevo. They concluded that the Trevo stent achieved more successful recanalization with less need for rescue treatment and less time for recanalization compared to solitaire but there was no significant difference in clinical outcomes in either stent used. Balloon guide catheter (BGC) was presumably used in all patients.[1]

In the authors' centre MRA with DWI, ADC and TOF angiography of neck and head is the preferred investigation. Most patients receive rtPA. DSA is done to document the occluded artery. Collateral circulation is documented if there is clinico-radiological discrepancy. 9F Balloon guide catheter is placed in corresponding ICA. The stent of choice is 6 mm x 30 mm unless there is occlusion beyond the M2 branch. 9F BCG allows strong aspiration with the open stent inside. The balloon is inflated when the stent is being withdrawn. When the stent is in the hub of the BCG, the “Y” adaptor is disconnected and strong suction applied on the BGC with the balloon inflated. Usually, clots are found in the BGC in addition to those in the stent. Long stents allow recanalization in the first pass. Both Solitaire and Trevo stent are associated with embolization in new territory (ENT). 1st pass recanalization was 59 0.8% and 31.3% (91.1% after two passes in our series). There was 71% clinical improvement to mRS 0 and 1 in our patients.[2]

The important aspect in the management of AIS care after 2014 is documenting LVO. MR CLEAN trial conducted in the Netherlands documented intracranial LVO using CT angiography or MR angiography or Digital subtraction angiography (DSA).[3] Patients with LVO do better with mechanical thrombectomy.

AHA/ASA guidelines for AIS management suggest that in patients eligible for EVT, angiography (CTA or MRA) should be done. Patients (age >18 years) who have had a pre-stroke mRS score of 0 to 1, NIHSS score of ≥6, ASPECTS score of ≥6 should undergo treatment with EVT within 6 hours from symptoms onset.[4]

A meta-analysis of five thrombectomy trials conducted between 2010 to 2014 showed that EVT is of benefit over the standard medical therapy alone in patients with AIS due to LVO in anterior circulation irrespective of patients' characteristics. The number needed to treat EVT to reduce the disability by one level on mRS for one patient is 2.6.[5]

Recently, two large multi-centric trials documented benefits of thrombectomy beyond 6 hours of the onset of symptoms. DEFUSE 3 trial concluded that in patients with proximal MCA and intracranial ICA occlusion with the onset of symptoms 6-16 hours, EVT and standard medical therapy were better than standard medical therapy alone. Volumes of ischemic core and penumbra regions on CT perfusion or MRI diffusion and perfusion scans were calculated using RAPID software (iSchemaView), an automated image post-processing system. Patients who had an initial infarct volume (ischemic core) of less than 70 ml, a ratio of the volume of ischemic tissue to initial infarct volume of 1.8 or more and an absolute volume of potentially reversible ischemia (penumbra) of 15 ml or more were enrolled.[6]

DAWN trial concluded that in patients with onset of symptoms between 6-24 hours with a mismatch between clinical deficit and infarct volume, EVT had a better 3-month outcome than standard medical therapy alone. Patients underwent CTA or MRA to document intracranial LVO and infarct volume was measured using RAPID software (iSchemaView) on DWI or perfusion CT.[7]

In LVO AIS early intervention with an onset-to-intervention time of less than 1 hour leads to better recanalization and better functional recovery at the end of 3 months. Bridging therapy with IVT in LVO AIS might delay the initiation of thrombectomy. Ongoing Direct Angio Trial is addressing this concern.[8]

Most of the trials have documented the effectiveness of EVT in anterior circulation AIS. A recent Indian study by the author's team has documented that EVT is safe and equally efficacious in the anterior and posterior circulation.[2]



 
  References Top

1.
Baek JW, Heo YJ, Kim ST, Seo JH, Jeong HW, Kim E. Comparison of the Solitaire and Trevo Stents for Endovascular Treatment of Acute Ischemic Stroke: A Single-center Experience. Neurol India 2021;69:378-382.  Back to cited text no. 1
  [Full text]  
2.
Singh RK, Chafale VA, Lalla RS, Panchal KC, Karapurkar AP, Khadilkar SV et al. Acute Ischemic Stroke Treatment Using Mechanical Thrombectomy: A Study of 137 Patients. Ann Indian Acad Neurol 2017;20:211-6. doi: 10.4103/aian.AIAN_158_17.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Berkhemer OA, Fransen P, Beumer D, Berg L, Lingsma H, Yoo A. et al. A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. N Engl J Med 2015;372:11-20. DOI: 10.1056/NEJMoa1411587.  Back to cited text no. 3
    
4.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye O M, Bambakidis NC, Becker K et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019;50:e344–e418. doi.org/10.1161/STR.0000000000000211.  Back to cited text no. 4
    
5.
Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM et al. Endovascular thrombectomy after large-vessel ischaemic stroke: A meta-analysis of individual patient data from five randomised trials. Lancet 2016;387:1723-31. doi: 10.1016/S0140-6736(16)00163-X.  Back to cited text no. 5
    
6.
Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Gutierrez SO, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med 2018;378:708-18. doi: 10.1056/NEJMoa1713973.  Back to cited text no. 6
    
7.
Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. N Engl J Med 2018;378:11-21. doi: 10.1056/NEJMoa1706442.  Back to cited text no. 7
    
8.
ClinicalTrials.gov [Internet]. National Library of Medicine (US). 2019 May 31 -. Identifier NCT03969511, Effect of DIRECT Transfer to ANGIOsuite on Functional Outcome in Severe Acute Stroke (DIRECTANGIO). 2019 May 31 [cited 2021 Mar 15]; Available from: http://https://clinicaltrials.gov/ct2/show/NCT03969511.  Back to cited text no. 8
    




 

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