Skip to main content
SpringerLink
Log in

Treatment of Acute Ischemic Stroke With Clot Retrieval Devices

  • Cerebrovascular Disease and Stroke (M Alberts and C Helgason, Section Editors)
  • Published:
Current Treatment Options in Cardiovascular Medicine Aims and scope Submit manuscript

Opinion statement

Mechanical clot retrieval is increasingly used for flow-restoration and thrombectomy in acute embolic stroke. Emerging as a treatment option in addition to intravenous or intra-arterial thrombolysis, it is currently being further developed and investigated as a potential first-line and stand-alone treatment. The ability to rapidly restore flow and effectively retrieve clots from large intracranial arteries is reflected by angiographic data and preliminary clinical results. This article reviews the principles and technical aspects of this new technique, its emergence from the spectrum of intravenous and endovascular stroke treatment, and summarizes the first clinical results for acute ischemic anterior and posterior circulation stroke. Clot retrieval devices are a very promising option for treatment of acute ischemic stroke in the setting of large vessel occlusion. However, there currently exists a reported discrepancy between excellent recanalization rates and less satisfactory clinical outcomes. This problem urgently needs to be addressed in a prospective randomized fashion and improvements of treatment be recognized and implemented before clot retrieval can be considered an established form of acute stroke treatment.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of Importance •• Of Major Importance

  1. Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics–2009 update: A report from the american heart association statistics committee and stroke statistics subcommittee. Circulation. 2009;119:480–6.

    Article  PubMed  Google Scholar 

  2. Tissue plasminogen activator for acute ischemic stroke. The national institute of neurological disorders and stroke rt-pa stroke study group. N Engl J Med. 1995;333:1581–1587

    Google Scholar 

  3. Wahlgren N, Ahmed N, Davalos A, et al. Thrombolysis with alteplase for acute ischaemic stroke in the safe implementation of thrombolysis in stroke-monitoring study (sits-most): An observational study. Lancet. 2007;369:275–82.

    Article  PubMed  CAS  Google Scholar 

  4. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 h after acute ischemic stroke. N Engl J Med. 2008;359:1317–29.

    Article  PubMed  CAS  Google Scholar 

  5. Lees KR, Bluhmki E, von Kummer R, et al. Time to treatment with intravenous alteplase and outcome in stroke: An updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet. 2010;375:1695–1703. This is the largest and most important pooled analysis from the relevant randomized trials on intravenous thrombolysis in acute ischemic stroke demonstrating the efficacy and the relevance of the time factor.

    Article  PubMed  CAS  Google Scholar 

  6. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: A meta-analysis. Stroke. 2007;38:967–73.

    Article  PubMed  Google Scholar 

  7. Nogueira RG, Liebeskind DS, Sung G, Duckwiler G, Smith WS. Predictors of good clinical outcomes, mortality, and successful revascularization in patients with acute ischemic stroke undergoing thrombectomy: Pooled analysis of the mechanical embolus removal in cerebral ischemia (merci) and multi merci trials. Stroke. 2009;40:3777–83.

    Article  PubMed  Google Scholar 

  8. del Zoppo GJ, Higashida RT, Furlan AJ, et al. PROACT: A phase ii randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke. Proact investigators. Prolyse in acute cerebral thromboembolism. Stroke. 1998;29:4–11.

    Article  PubMed  Google Scholar 

  9. Barnwell SL, Clark WM, Nguyen TT, et al. Safety and efficacy of delayed intraarterial urokinase therapy with mechanical clot disruption for thromboembolic stroke. AJNR Am J Neuroradiol. 1994;15:1817–22.

    PubMed  CAS  Google Scholar 

  10. Gobin YP, Starkman S, Duckwiler GR, et al. Merci 1: A phase 1 study of mechanical embolus removal in cerebral ischemia. Stroke. 2004;35:2848–54.

    Article  PubMed  Google Scholar 

  11. Nakano S, Iseda T, Yoneyama T, Kawano H, Wakisaka S. Direct percutaneous transluminal angioplasty for acute middle cerebral artery trunk occlusion: An alternative option to intra-arterial thrombolysis. Stroke. 2002;33:2872–6.

    Article  PubMed  Google Scholar 

  12. Bergui M, Stura G, Daniele D, et al. Mechanical thrombolysis in ischemic stroke attributable to basilar artery occlusion as first-line treatment. Stroke. 2006;37:145–50.

    Article  PubMed  Google Scholar 

  13. The interventional management of stroke (ims) ii study. Stroke. 2007;38:2127–2135

    Google Scholar 

  14. Smith WS, Sung G, Saver J, et al. Mechanical thrombectomy for acute ischemic stroke: Final results of the multi merci trial. Stroke. 2008;39:1205–12.

    Article  PubMed  Google Scholar 

  15. The penumbra pivotal stroke trial: Safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. Stroke. 2009;40:2761–2768. This is a relevant study on one of the two FDA-approved devices (Penumbra). The study comes closer to a concept of primary mechanical clot removal rather than to a rescue (ie, “bridging”) concept after an intravenous trial as in many other studies.

    Article  Google Scholar 

  16. Abou-Chebl A, Bajzer CT, Krieger DW, Furlan AJ, Yadav JS. Multimodal therapy for the treatment of severe ischemic stroke combining gpiib/iiia antagonists and angioplasty after failure of thrombolysis. Stroke. 2005;36:2286–8.

    Article  PubMed  CAS  Google Scholar 

  17. Gupta R, Vora NA, Horowitz MB, et al. Multimodal reperfusion therapy for acute ischemic stroke: Factors predicting vessel recanalization. Stroke. 2006;37:986–90.

    Article  PubMed  Google Scholar 

  18. Levy EI, Mehta R, Gupta R, et al. Self-expanding stents for recanalization of acute cerebrovascular occlusions. AJNR Am J Neuroradiol. 2007;28:816–22.

    PubMed  CAS  Google Scholar 

  19. Zaidat OO, Wolfe T, Hussain SI, et al. Interventional acute ischemic stroke therapy with intracranial self-expanding stent. Stroke. 2008;39:2392–5.

    Article  PubMed  Google Scholar 

  20. Mocco J, Hanel RA, Sharma J, et al. Use of a vascular reconstruction device to salvage acute ischemic occlusions refractory to traditional endovascular recanalization methods. J Neurosurg. 2010;112:557–62.

    Article  PubMed  CAS  Google Scholar 

  21. Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke. The proact ii study: A randomized controlled trial. Prolyse in acute cerebral thromboembolism. JAMA. 1999;282:2003–11.

    Article  PubMed  CAS  Google Scholar 

  22. Ogawa A, Mori E, Minematsu K, et al. Randomized trial of intraarterial infusion of urokinase within 6 h of middle cerebral artery stroke: The middle cerebral artery embolism local fibrinolytic intervention trial (melt) japan. Stroke. 2007;38:2633–9.

    Article  PubMed  CAS  Google Scholar 

  23. Lee M, Hong KS, Saver JL. Efficacy of intra-arterial fibrinolysis for acute ischemic stroke: Meta-analysis of randomized controlled trials. Stroke. 2010;41:932–7.

    Article  PubMed  Google Scholar 

  24. Lindsberg PJ, Mattle HP. Therapy of basilar artery occlusion: A systematic analysis comparing intra-arterial and intravenous thrombolysis. Stroke. 2006;37:922–8.

    Article  PubMed  Google Scholar 

  25. Schonewille WJ, Wijman CA, Michel P, et al. Treatment and outcomes of acute basilar artery occlusion in the basilar artery international cooperation study (basics): A prospective registry study. Lancet Neurol. 2009;8:724–730. These are the best data so far on basilar occlusion treatment.

    Article  PubMed  Google Scholar 

  26. Mahon BR, Nesbit GM, Barnwell SL, et al. North american clinical experience with the ekos microlysus infusion catheter for the treatment of embolic stroke. AJNR Am J Neuroradiol. 2003;24:534–8.

    PubMed  Google Scholar 

  27. Levy EI, Siddiqui AH, Crumlish A, et al. First food and drug administration-approved prospective trial of primary intracranial stenting for acute stroke: SARIS (stent-assisted recanalization in acute ischemic stroke). Stroke. 2009;40:3552–6.

    Article  PubMed  Google Scholar 

  28. Castano C, Dorado L, Guerrero C, et al. Mechanical thrombectomy with the solitaire ab device in large artery occlusions of the anterior circulation: A pilot study. Stroke. 2010;41:1836–1840. This is the first important study on a stent-retriever for acute ischemic stroke treatment.

    Article  PubMed  Google Scholar 

  29. Stampfl S, Hartmann M, Ringleb PA, et al. Stent placement for flow restoration in acute ischemic stroke: A single-center experience with the solitaire stent system. AJNR Am J Neuroradiol. 2011;32:1245–8.

    Article  PubMed  CAS  Google Scholar 

  30. Costalat V, Machi P, Lobotesis K, Maldonado I, Vendrell JF, Riquelme C, Mourand I, Milhaud D, Heroum C, Perrigault PF, Arquizan C, Bonafe A. Rescue, combined, and stand-alone thrombectomy in the management of large vessel occlusion stroke using the solitaire device: A prospective 50-patient single-center study: Timing, safety, and efficacy. Stroke. 2011;42:1929–1935. This is the largest study so far on the application of a stent-retriever for acute ischemic stroke treatment.

    Article  PubMed  Google Scholar 

  31. Wehrschuetz M, Wehrschuetz E, Augustin M, et al. Early single center experience with the solitaire thrombectomy device for the treatment of acute ischemic stroke. Interv Neuroradiol. 2011;17:235–40.

    PubMed  CAS  Google Scholar 

  32. Cohen JE, Gomori JM, Leker RR, et al. Preliminary experience with the use of self-expanding stent as a thrombectomy device in ischemic stroke. Neurol Res. 2011;33:214–9.

    Article  PubMed  Google Scholar 

  33. Mohlenbruch M, Seifert M, Okulla T, et al. Mechanical thrombectomy compared to local-intraarterial thrombolysis in carotid t and middle cerebral artery occlusions: A single center experience. Clin Neuroradiol. 2011

  34. Rohde S, Haehnel S, Herweh C, et al. Mechanical thrombectomy in acute embolic stroke: Preliminary results with the revive device. Stroke. 2011

  35. Mazighi M, Serfaty JM, Labreuche J, et al. Comparison of intravenous alteplase with a combined intravenous-endovascular approach in patients with stroke and confirmed arterial occlusion (recanalise study): A prospective cohort study. Lancet Neurol. 2009;8:802–809. This is the largest and most important analysis on the “bridging concept” (ie. combined intravenous-endovascular management of acute ischemic stroke).

    Article  PubMed  CAS  Google Scholar 

  36. Roth C, Mielke A, Siekmann R, Ferbert A. First experiences with a new device for mechanical thrombectomy in acute basilar artery occlusion. Cerebrovasc Dis. 2011;32:28–34.

    Article  PubMed  CAS  Google Scholar 

  37. Pfefferkorn T, Mayer TE, Opherk C, et al. Staged escalation therapy in acute basilar artery occlusion: Intravenous thrombolysis and on-demand consecutive endovascular mechanical thrombectomy: Preliminary experience in 16 patients. Stroke. 2008;39:1496–500.

    Article  PubMed  Google Scholar 

  38. Tomsick T, Brott T, Barsan W, et al. Prognostic value of the hyperdense middle cerebral artery sign and stroke scale score before ultraearly thrombolytic therapy. AJNR Am J Neuroradiol. 1996;17:79–85.

    PubMed  CAS  Google Scholar 

  39. Abou-Chebl A, Lin R, Hussain MS, Jovin TG, et al. Conscious sedation versus general anesthesia during endovascular therapy for acute anterior circulation stroke: Preliminary results from a retrospective, multicenter study. Stroke. 2010;41:1175–1179. This is a very interesting retrospective analysis suggesting disadvantages of general anesthesia for endovascular stroke treatment.

    Article  PubMed  CAS  Google Scholar 

  40. Roth C, Papanagiotou P, Behnke S, et al. Stent-assisted mechanical recanalization for treatment of acute intracerebral artery occlusions. Stroke. 2010;41:2559–67.

    Article  PubMed  CAS  Google Scholar 

Download references

Disclosure

J. Bösel: none. W. Hacke has received consulting fees, honoraria, and had travel expenses covered by Codman. M. Bendszus is a consultant for Codman, has received speaker’s honoraria from Codman, Micrus, and eV3, had had travel expenses/accommodations reimbursed by Codman, Micrus, and eV3, and has received payment for development of educational programs from Micrus. S. Rohde has received honoraria from Codman.

Author information

Authors and Affiliations

  1. Department of Neurology, University of Heidelberg, Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany

    Julian Bösel MD & Werner Hacke PhD

  2. Department of Neuroradiology, University of Heidelberg, Im Neuenheimer Feld 400, D-69120, Heidelberg, Germany

    Martin Bendszus PhD & Stefan Rohde MD

Authors
  1. Julian Bösel MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Werner Hacke PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Martin Bendszus PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Stefan Rohde MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Julian Bösel MD.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Bösel, J., Hacke, W., Bendszus, M. et al. Treatment of Acute Ischemic Stroke With Clot Retrieval Devices. Curr Treat Options Cardio Med 14, 260–272 (2012). https://doi.org/10.1007/s11936-012-0172-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11936-012-0172-y

Keywords

Search

Navigation