AUTHORS: Carroll JJ, Lavine SD, Meyers PM.

Powerful new data from multiple randomized-controlled trials published in 2015 proved that mechanical thrombectomy with stent retrievers is superior to standard medical care in the treatment of carefully selected patients with acute ischemic stroke caused by large vessel occlusion in the proximal anterior circulation. Further studies in 2018 demonstrated the efficacy of mechanical thrombectomy in select patients up to 24 hours after onset of symptoms. It has been shown that direct aspiration can be used as an alternative to stent retrievers in acute ischemic stroke.

Acute ischemic stroke affects nearly 800,000 patients in the United States annually and is one of the leading causes of morbidity and mortality (07). Intracranial large vessel occlusion, most commonly involving the proximal middle cerebral artery or intracranial internal carotid artery, occurs in approximately 30% of acute ischemic strokes (32). Until recently, the only proven therapy for acute ischemic stroke was the administration of intravenous recombinant tissue plasminogen activator (IV-rtPA) within 4.5 hours of symptom onset (42; 22; 15). Although timely administration of IV-rtPA improves functional independence at 90 days, it does not reduce mortality versus placebo (42; 22; 15). Additionally, recanalization rates of acute ischemic stroke with large vessel occlusion treated with IV-rtPA remain extremely low (09; 24; 07). This is an important concept because large vessel occlusion recanalization rates are closely associated with good outcomes and reduced mortality (09; 18; 07). Furthermore, several studies have demonstrated a link between failed IV-rtPA recanalization and clot burden, suggesting there is a limit to the efficacy of IV-rtPA in the setting of large vessel occlusion (09; 59; 07). The limitations of IV-rtPA in the setting of large vessel occlusion have led to the emergence and rapid evolution of intraarterial therapies for the treatment of acute ischemic stroke.

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