New gold standard treatment for acute stroke : endovascular thrombectomy using stentretrievers

Abstract

The last year has seen the most dramatic advance in the treatment of acute stroke since the United States National Institutes of Health tissue plasminogen activator (tPA) study showed in 1995 that intravenous (IV) thrombolysis delivered within three hours of stroke onset could improve outcome. IV tPA became standard treatment for acute stroke after that study, but there was still difficulty in recanalising large vessel occlusions and up to one half of patients were left with severe deficits despite IV tPA. In 2008, the European Cooperative Acute Stroke Study (ECASS) III extended the IV tPA time window from three to four and a half hours from stroke onset but favourable outcome at 90 days was still only seen in 52% of patients, as in other studies. In cardiology, it was demonstrated that endovascular treatments were superior to IV, but it appeared that this was going to be one area where stroke differed. Repeated endovascular studies, the largest of which was Interventional Management of Stroke (IMS) III trial showed no advantage over IV tPA. The only exception was the borderline results of the Prolyse in Acute Thromboembolism (PROACT) II trial in 1999. One common recurring theme was the need for early recanalization for maximal benefit and the decreased recanalization noted with larger clot burden.