7 Identifying Patients for Stroke Thrombectomy

Mithun G. Sattur, Evelyn L. Turcotte, Devi P. Patra, Karl Abi-Aad, Matthew E. Welz, Miles Hudson, and Bernard R. Bendok

Abstract

Identification of patients for stroke thrombectomy begins with a proper diagnosis of acute ischemic stroke (AIS). Upon suspicion of AIS, timely communication (including through telehealth) between paramedics, emergency department staff, and stroke specialists is the key to accelerate triage of AIS patients. Determining the last known normal (LKN) status includes obtaining a thorough history, conducting a physical examination, and determining the National Institutes of Health Stroke Scale (NIHSS) score. This will help further categorize the severity of the stroke and, in conjunction with imaging findings, will determine appropriate treatment options. The purpose of imaging is to (1) exclude the presence of hemorrhage, (2) rule out other pathologies that may mimic an AIS, (3) determine the location and extent of the occlusion, and (4) estimate tissue at risk in patients presenting 6 to 24 hours after LKN finding of large vessel occlusion. Alberta Stroke Program early CT Score (ASPECTS) > 6, NIHSS > 6, and parameters satisfying adequate tissue at risk or salvageable penumbra (for 6- to 24-hour time window) are the main eligibility criteria for mechanical thrombectomy (MT). Penumbra volume can be calculated by automated software that allows for faster interpretation of imaging findings. Multiple studies are challenging the current eligibility criteria dictated by the American Heart Association/American Stroke Association (AHA/ASA) guidelines and are demonstrating promising results in patients otherwise noneligible for MT such as patients with low NIHSS, low ASPECTS, and patients presenting beyond the 24-hour window of opportunity. These efforts will potentially widen the eligibility criteria for MT and bring further changes to current AIS guidelines.

Key words

mechanical thrombectomy - acute ischemic stroke - large vessel occlusion - patient eligibility

• 1 Fayad P. Improved prospects for thrombectomy in large ischemic stroke.. N Engl J Med 2023; 388 (14) 1326-1328 PubMed

• 2 Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke.. N Engl J Med 2015; 372 (1) 11-20 PubMed

• 3 Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke.. N Engl J Med 2015; 372 (11) 1019-1030 PubMed

• 4 Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke.. N Engl J Med 2015; 372 (24) 2296-2306 PubMed

• 5 Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke.. N Engl J Med 2015; 372 (24) 2285-2295 PubMed

• 6 Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection.. N Engl J Med 2015; 372 (11) 1009-1018 PubMed

• 7 Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct.. N Engl J Med 2018; 378 (1) 11-21 PubMed

• 8 Albers GW, Marks MP, Kemp S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging.. N Engl J Med 2018; 378 (8) 708-718 PubMed

• 9 Powers WJ, Rabinstein AA, Ackerson T et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke—a guideline for healthcare professionals from the American Heart Association/American Stroke Association.. Stroke 2019; 50 (12) e344-e418 PubMed

• 10 Jovin TG, Saver JL, Ribo M et al. Diffusion-weighted imaging or computerized tomography perfusion assessment with clinical mismatch in the triage of wake up and late presenting strokes undergoing neurointervention with Trevo (DAWN) trial methods.. Int J Stroke 2017; 12 (6) 641-652 PubMed

• 11 Albers GW, Lansberg MG, Kemp S et al. A multicenter randomized controlled trial of endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE 3).. Int J Stroke 2017; 12 (8) 896-905 PubMed

• 12 Lapergue B, Blanc R, Costalat V, et al. Effect of thrombectomy with combined contact aspiration and stent retriever vs. stent retriever alone on revascularization in patients with acute ischemic stroke and large vessel occlusion: the ASTER2 randomized clinical trial.. JAMA 2021; 326 (12) 1158-1169 PubMed

• 13 Fugate JE, Klunder AM, Kallmes DF. What is meant by “TICI”?. AJNR Am J Neuroradiol 2013; 34 (9) 1792-1797 PubMed

• 14 Zaidat OO, Yoo AJ, Khatri P, et al. , , Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement.. Stroke 2013; 44 (9) 2650-2663 PubMed

• 15 Tomsick T, Broderick J, Carrozella J, et al. Revascularization results in the Interventional Management of Stroke II trial.. AJNR Am J Neuroradiol 2008; 29 (3) 582-587 PubMed

• 16 Uchida K, Shindo S, Yoshimura S, et al. Association between Alberta Stroke Program Early Computed Tomography Score and efficacy and safety outcomes with endovascular therapy in patients with stroke from large-vessel occlusion: a secondary analysis of the Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism-Japan Large Ischemic Core Trial (RESCUE-Japan LIMIT).. JAMA Neurol 2022; 79 (12) 1260-1266 PubMed

• 17 Huo X, Ma G, Tong X, et al. Trial of endovascular therapy for acute ischemic stroke with large infarct.. N Engl J Med 2023; 388 (14) 1272-1283 PubMed

• 18 Sarraj A, Hassan AE, Abraham MG, et al. Trial of endovascular thrombectomy for large ischemic strokes.. N Engl J Med 2023; 388 (14) 1259-1271 PubMed

• 19 Zaidat OO, Kasab SA, Sheth S et al. TESLA trial: rationale, protocol, and design.. Stroke Vasc Intervent Neurol 2023; 3 (4) e000787

• 20 Yoo AJ, Zaidat OO; TESLA Investigators. TESLA trial: primary results. Paper presented at: ESOC 2023; May 24–26, 2023; Munich

• 21 Palaiodimou L, Sarraj A, Safouris A et al. Endovascular treatment for large-core ischaemic stroke: a meta-analysis of randomised controlled clinical trials.. J Neurol Neurosurg Psychiatry 2023; 94 (10) 781-785 PubMed

• 22 Saver JL, Chapot R, Agid R, et al. Thrombectomy for distal, medium vessel occlusions: a consensus statement on present knowledge and promising directions.. Stroke 2020; 51 (9) 2872-2884 PubMed

• 23 Schulze-Zachau V, Brehm A, Ntoulias N et al. Incidence and outcome of perforations during medium vessel occlusion compared with large vessel occlusion thrombectomy.. J Neurointerv Surg 2023; (e-pub ahead of print) PubMed

• 24 Al Kasab S, Almallouhi E, Alawieh A, et al. Outcomes of rescue endovascular treatment of emergent large vessel occlusion in patients with underlying intracranial atherosclerosis: insights from STAR.. J Am Heart Assoc 2021; 10 (12) e020195 PubMed

• 25 Poppe AY, Jacquin G, Roy D, Stapf C, Derex L. Tandem carotid lesions in acute ischemic stroke: mechanisms, therapeutic challenges, and future directions.. AJNR Am J Neuroradiol 2020; 41 (7) 1142-1148 PubMed

• 26 Anadani M, Spiotta AM, Alawieh A, et al. Emergent carotid stenting plus thrombectomy after thrombolysis in tandem strokes: analysis of the TITAN registry.. Stroke 2019; 50 (8) 2250-2252 PubMed

• 27 Allard J, Delvoye F, Pop R, et al. 24-hour carotid stent patency and outcomes after endovascular therapy: a multicenter study.. Stroke 2023; 54 (1) 124-131 PubMed

• 28 Liu X, Dai Q, Ye R, et al. Endovascular treatment versus standard medical treatment for vertebrobasilar artery occlusion (BEST): an open-label, randomised controlled trial.. Lancet Neurol 2020; 19 (2) 115-122 PubMed

• 29 Langezaal LCM, van der Hoeven EJRJ, Mont’Alverne FJA, et al. Endovascular therapy for stroke due to basilar-artery occlusion.. N Engl J Med 2021; 384 (20) 1910-1920 PubMed

• 30 Tao C, Nogueira RG, Zhu Y, et al. Trial of endovascular treatment of acute basilar-artery occlusion.. N Engl J Med 2022; 387 (15) 1361-1372 PubMed

• 31 Jovin TG, Li C, Wu L, et al. Trial of thrombectomy 6 to 24 hours after stroke due to basilar-artery occlusion.. N Engl J Med 2022; 387 (15) 1373-1384 PubMed

• 32 Puetz V, Khomenko A, Hill MD, et al. Extent of hypoattenuation on CT angiography source images in basilar artery occlusion: prognostic value in the Basilar Artery International Cooperation Study.. Stroke 2011; 42 (12) 3454-3459 PubMed

• 33 Hafeez MU, Essibayi MA, Raper D, et al. Predictors and outcomes of first pass efficacy in posterior circulation strokes: insights from STAR collaboration.. Interv Neuroradiol 2022; (e-pub ahead of print) PubMed

• 34 Meyer L, Stracke CP, Jungi N et al. Thrombectomy for primary distal posterior cerebral artery occlusion stroke: the TOPMOST study.. JAMA Neurol 2021; 78 (4) 434-444 PubMed

• 35 Nguyen TN, Qureshi MM, Strambo D et al. Endovascular versus medical management of posterior cerebral artery occlusion stroke: the PLATO study.. Stroke 2023; 54 (7) 1708-1717 PubMed

• 36 McCarthy DJ, Tonetti DA, Stone J et al. More expansive horizons: a review of endovascular therapy for patients with low NIHSS scores.. J Neurointerv Surg 2021; 13 (2) 146-151 PubMed

• 37 Abecassis IJ, Almallouhi E, Chalhoub RM et al. The effect of occlusion location and technique in mechanical thrombectomy for minor stroke.. Interv Neuroradiol 2023; (e-pub ahead of print) PubMed

• 38 Adamou A, Gkana A, Mavrovounis G, Beltsios ET, Kastrup A, Papanagiotou P. Outcome of endovascular thrombectomy in pre-stroke dependent patients with acute ischemic stroke: a systematic review and meta-analysis.. Front Neurol 2022; 13: 880046 PubMed

• 39 Miyake S, Akimoto T, Nakai Y et al. Efficacy and safety of thrombectomy for acute ischaemic stroke in patients with pre-stroke mRS scores of 2–3: real-world evaluation from an open-label, prospective, multicentre, observational study.. Interv Neuroradiol 2023; (e-pub ahead of print) PubMed

• 40 Grisold W, Oberndorfer S, Struhal W. Stroke and cancer: a review.. Acta Neurol Scand 2009; 119 (1) 1-16 PubMed

• 41 Duan L, Fu Z, Zhao H et al. Outcomes after endovascular thrombectomy for acute ischemic stroke patients with active cancer: a systematic review and meta-analysis.. Front Neurol 2022; 13: 992825 PubMed

• 42 Shalabi F, Aladdin S, Molad J et al. Effects of tumor type on outcomes in patients with large vessel occlusion stroke and cancer.. J Stroke Cerebrovasc Dis 2023; 32 (9) 107288 PubMed