
HOSPITAL REPORT
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Mechanical Thrombectomy for Stroke: The Bullet Points
January 27th, 2025

Introduction and Background
Stroke is a leading global health issue, with ischemic stroke accounting for a majority of cases. Mechanical thrombectomy (MT) has emerged as a transformative treatment for acute ischemic strokes caused by large vessel occlusions (LVOs), significantly improving outcomes. MT involves the physical removal of clots via endovascular techniques, typically within 24 hours of symptom onset. Imaging technologies such as CT angiography (CTA) and computed tomography perfusion (CTP) are crucial in identifying candidates for MT by assessing salvageable brain tissue and occlusion sites.
Advancements in Treatment
- Endovascular therapy (EVT): This broad term includes MT and other catheter-based interventions such as intra-arterial thrombolysis, stent placement, and balloon angioplasty. MT specifically involves clot retrieval using stent retrievers or aspiration catheters.
- Efficacy of MT: Clinical trials (MR CLEAN, DAWN, DEFUSE-3) demonstrate that MT significantly reduces disability when performed within 6 to 24 hours of symptom onset. MT is often used in conjunction with intravenous thrombolysis (IVT), particularly tenecteplase (TNK), which has shown promise because of its ease of administration and improved recanalization rates.
Pathophysiology and Timing
- Ischemic cascade: Acute LVO interrupts cerebral blood flow, causing irreversible damage to the ischemic core while leaving surrounding penumbral tissue salvageable if blood flow is promptly restored.
- Time sensitivity: The concept of "time is brain" underlines the importance of timely intervention to salvage penumbral tissue. MT is most effective within six hours but can be extended to 24 hours for selected patients with favorable imaging profiles.
Epidemiology
Stroke affects 12 million people annually, with rising incidence in low- and middle-income countries (LMICs) because of aging populations and modifiable risk factors like obesity and diabetes. Women experience worse outcomes due to disparities in access to advanced therapies like MT.
Diagnosis and Imaging
- Non-contrast CT (NCCT): Rules out hemorrhage but may not detect early ischemic changes.
- CTA: Identifies LVOs with high sensitivity and specificity.
- CTP: Distinguishes salvageable penumbra from irreversibly infarcted core tissue, guiding MT eligibility.
- MRI: Considered the gold standard for stroke imaging, though less commonly used due to logistical challenges.
- Prehospital and in-hospital tools: Mnemonics like FAST and BEFAST help rapidly identify stroke symptoms. Scales like the National Institutes of Health Stroke Scale (NIHSS) and ASPECTS score guide treatment decisions and predict outcomes.
Management
- Mechanical thrombectomy (MT): MT is the standard of care for LVO strokes within 24 hours of symptom onset. Success depends on patient selection, imaging findings, and timely intervention.
- Pharmacologic adjuncts:
- IV thrombolytics like TNK or alteplase should be administered within 4.5 hours of symptom onset, even if MT is planned.
- Dual antiplatelet therapy (DAPT) is recommended post-MT to reduce stroke recurrence.
- Periprocedural complications:
- Risks include access site complications, vasospasm, symptomatic intracerebral hemorrhage, and cerebral edema. Close monitoring is essential to manage these risks.
Patient Selection and Emerging Data
- Expanded indications: MT is now being considered for select patients with distal vessel occlusions, minor deficits (NIHSS < 5), or advanced age (>80 years). Ongoing trials aim to clarify its efficacy in these populations.
- Pregnancy: Limited evidence supports MT in pregnant patients, but case reports suggest it may be safe with appropriate multidisciplinary care.
Post-Procedural Care
Patients typically require intensive care unit (ICU) monitoring for 24-48 hours post-MT. Key considerations include:
- Frequent neurologic assessments
- Blood pressure control (target systolic < 180 mmHg)
- Monitoring for complications like re-occlusion or cerebral edema
- Initiation of enteral feeding and DVT prophylaxis
Outcomes and Future Directions
MT has significantly improved functional outcomes and reduced disability in stroke patients. Emerging techniques, improved imaging protocols, and expanding eligibility criteria promise further advancements. However, challenges remain in optimizing access to care, particularly in LMICs and underserved populations.
For a more expansive look at how mechanical thrombectomy can help stroke patients, click here.