Endovascular treatment for acute stroke: appropriate treatment strategy using multi modal device

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  • TATESHIMA Satoshi
    Division of Interventional Neuroradiology, Ronald Reagan UCLA Medical Center
  • SAKAI Nobyuki
    Department of Neurosurgery and Stroke Center, Kobe City Medical Center General Hospital

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Other Title
  • 急性期虚血性脳卒中の脳血管内治療：複数デバイス時代に備えた適切な治療法の選択とは
  • キュウセイキキョケツセイ ノウソッチュウ ノ ノウケッカン ナイ チリョウ フクスウ デバイス ジダイ ニ ソナエタ テキセツ ナ チリョウホウ ノ センタク トワ

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Abstract

The intravenous (IV) administration of recombinant tissue plasminogen activator (rtPA), which is supported by the highest level of scientific evidence, continues to be the gold standard for the treatment of acute ischemic stroke following a major vessel occlusion. Nevertheless, not all patients are eligible to receive IV rtPA, and rates of recanalization remain greatly variable depending on the site of occlusion. The advent of endovascular treatment appeared as a very attractive alternative for those who had failed, or were ineligible for, IV rtPA. In addition to the preexisting endovascular treatment modalities such as local fibrinolytic therapy and balloon angioplasty / stenting, mechanical thrombectomy has been incorporated in the treatment options to restore cerebral perfusion to the downstream region. Merci® Retriever and Penumbra System® were approved by the United States Food and Drug Administration (FDA), for the treatment of acute ischemic stroke in 2004 and 2008, respectively. Likewise, Merci® Retriever and Penumbra® received an approval by the Japanese Ministry of Health, Labor and Welfare in 2010 and 2011, respectively. The endovascular treatment of acute ischemic stroke has ushered in a new age of multipledevices, whereby the selection of an appropriate device becomes vital. In this article, the authors present clinical cases, in which Merci® Retriever (a device that applies force to the distal base of the thrombus), Penumbra System® (a device that applies force to the proximal base of the thrombus), stent-retriever (a device meant to be placed across the thrombus), direct angioplasty and permanent stent placement, and local fibrinolytic injections were utilized. The theoretical advantages and disadvantages of these devices and treatment modalities were also discussed in the clinical case presentations. The poor overall outcome associated with nonrecanalized major vessel occlusion is well recognized. Proper indication and successful recanalization of the occluded vessel are the keys to achieve the good clinical outcome. Newer generation devices are not necessarily associated with a higher recanalization rate. It is appropriate device selection based on the functional mechanism and the type of the occlusion that enables a higher rate of recanalization.

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