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Cardio Diabetes Medicine 2017 507

Stroke Thrombectomy

Dr. A.L. Periyakaruppan, MDRD.,
Neuro interventional Radiologist, Chennai

AIM : Sylvian fissure) and virtually no anterior or posterior
Endovascular thrombectomy for large vessel isch- cerebral artery occlusions were treated.
aemic stroke substantially reduces disability, with Do clinical variables influence benefit from thrombec-
recent positive randomised trials leading to guideline tomy? - Greater clinical severity has been suggested
changes worldwide as a marker of improved response to endovascular

Robust benefit of endovascular thrombectomy for thrombectomy
internal carotid and proximal middle cerebral artery Stroke severity: Patients with National Institutes of
occlusions Health Stroke Scale (NIHSS) ≥6 definitely benefit. Mild-
er patients still have approximately 10% incidence of
Uncertainty remains for more distal occlusions where
the efficacy of alteplase is greater, less tissue is at large vessel occlusion and so CT angiography (CTA)
risk and the safety of endovascular procedures is should be routine. This group has a high risk of later
less established deterioration. Tandem occlusion of the internal carot-
id artery: Very strong benefit in this subpopulation.
The brain imaging options to assess prognosis have Distal MCA (M2) occlusion: Uncertain benefit in trials
various advantages and disadvantages, but whatever
strategy is employed must be fast. Patients with ASPECTS 6–10 definitely benefit. If AS-
PECTS 0–5 benefit is uncertain
INTRODUCTION Patients with CTP core < 70 mL definitely benefit and
Endovascular thrombectomy for large vessel isch- CTP > 70 ml benefit is uncertain
aemic stroke has been demonstrated in recent ran- Collateral grade—patients with moderate to good col-
domised trials to be one of the most powerful treat- laterals definitely benefit
ments in any field of medicine, with a number needed
to treat of 5.1 patients to achieve an extra individual There is widespread consensus that the current stan-
with independent functional outcome. dard of mTICI 2b/3 (>50% reperfusion of the affected
arterial territory) is too lenient.
IDENTIFYING LARGE VESSEL OCCLUSION
All the positive trials required proof of large vessel CONCLUSIONS
occlusion using non-invasive angiography, mostly The key principles that can be distilled from the
CT angiography (CTA). An unequivocally hyperdense positive endovascular trials are to achieve rapid and
artery, particularly when visualised using thin slice complete reperfusion, and to consider the extent of
non-contrast CT, has high sensitivity and specificity pre-existing irreversible injury when weighing the po-
for acute occlusive thrombus tential risks and benefits of treatment
Which arterial occlusions are suitable for thrombec- Recommendations
tomy? The trials all included intracranial internal ca-
rotid artery (ICA) and middle cerebral artery (MCA) All stroke patients should be managed as a time crit-
occlusions in the ‘M1’ (horizontal segment proximal ical emergency.
to the Sylvian fissure and usually prior to bifurcation). Highest level of priority should also be provided when
Relatively few ‘M2’ occlusions (postbifurcation in the transporting suspected stroke patients to hospitals

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