Update on Large-Vessel Revascularization in Acute Ischemic Stroke

• Published in: Current treatment options in neurology Vol. 25; no. 8; pp. 241 - 259
• Main Authors: Saini, Vasu, Sharashidze, Vera, Abecassis, Isaac Josh, Guada, Luis, Charles, Jude Hassan, Limaye, Kaustubh, Yavagal, Dileep R.
• Format: Journal Article
• Language: English
• Published: New York Springer US 01.08.2023
• Subjects: Critical Care Medicine; Diabetes; Family Medicine; General Practice; Intensive; Internal Medicine; Medicine; Medicine & Public Health; Neurology; Ophthalmology; Topical Collection on Cerebrovascular Disorders; Endovascular thrombectomy; Stroke; Large-vessel occlusion; Mechanical thrombectomy; Large ischemic core; Medium-vessel occlusion; Ischemic stroke; Revascularization
• ISSN: 1092-8480; 1534-3138
• DOI: 10.1007/s11940-023-00758-3

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.