The following are key points to remember from a review on endovascular management of acute stroke:

1. The current article reviews the recent randomized trial data for endovascular therapy of acute stroke, reviews current devices, and addresses ongoing areas under study.
2. Deprivation of blood flow leads to an ischemic cascade and acute injury to neuronal tissues. Affected areas are the area of core, which constitutes the area of tissue likely to be irreversibly injured, and the penumbra, which is the area of ischemic tissue that is critically hypoperfused and at risk for infarction.
3. The aim of intravenous thrombolysis or endovascular therapy is to restore blood flow to the occluded artery and thereby salvage the penumbra, or the at-risk and neurologically dysfunctional region of tissue, consequently restoring a patient’s neurological function. Randomized trials using the new generation of devices have unequivocally confirmed the benefit of endovascular therapy over best medical treatment in selected patients.
4. In the early 2000s, mechanical thrombectomy devices like the Merci Retrieval System (using helical nitinol coils to ensnare clots) and the Penumbra clot aspiration system were approved for acute recanalization. Permanent intracranial stenting emerged as a viable treatment option, showing favorable angiographic patency and clinical outcomes in a prospective trial.
5. The introduction of stent retrievers heralded an improvement in reperfusion rates and clinical outcomes. Stent retrievers offered immediate flow restoration upon deployment, relying on stent radial force for thrombus penetration before retrieval. Randomized controlled trials of stent retrievers, including TREVO 2 and SWIFT, showed superior reperfusion rates and improved clinical outcomes compared with the Merci retriever.
6. Earlier trials confirmed the benefits of endovascular therapy for small core strokes within the early window (within 6 hours) and in 2018, this benefit was extended to the 6- to 24-hour window.
7. Reperfusion hemorrhage and the development of malignant cerebral edema have been the concerns of reperfusion in patients with a large ischemic core. Current evidence supports the treatment of subsets of patients with large ischemic cores up to the 24-hour window.
8. Meta-analyses of randomized controlled trials for basilar artery occlusion have shown a treatment effect in favor of endovascular therapy in most patients with moderate-to-severe basilar artery occlusion and less certainty for patients with mild deficit.
9. Administration of intravenous thrombolysis before endovascular therapy is recommended by current guidelines but there is ongoing debate about the value of intravenous thrombolysis in combination with endovascular therapy in patients directly admitted to endovascular therapy centers.
10. Large vessel occlusion with intracranial atherosclerotic disease is associated both with a >3-fold risk of re-occlusion and with procedural challenges due to vessel wall disruption when compared with patients who do not have large vessel atherosclerosis. Based on current evidence, rescue angioplasty and stenting should be restricted to patients at high risk of re-occlusion despite antiplatelet agents.
11. Management of occlusion of medium or distal vessels is challenging due to small caliber arteries and tortuosity. Several trials are testing whether endovascular therapy with a device or intra-arterial thrombolytic therapy is superior to medical management in patients with medium vessel occlusion or incomplete reperfusion after thrombectomy.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Interventions and Vascular Medicine, Vascular Medicine

Keywords: Endovascular Procedures, Stroke, Thrombectomy

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