Abstract

Mechanical thrombectomy is now well - established first - line treatment for selected patients with large artery occlusions of the anterior circulation. However, number of technical and procedural issues remains open to assure optimal outcomes in majority of patients including those suffering from posterior circulation perfusion defects. This brief review addresses some of the open issues and refers to the ongoing trials to close the existing knowledge gaps.

Mechanical thrombectomy, acute ischemic stroke, state-of-the-art, agenda 2020
Topic:

Introduction

In 2015, the MR CLEAN randomized trial has proven the superior effectiveness of endovascular thrombectomy (EVT) over systemic thrombolysis (ST) in selected patients with cerebral large-vessel occlusions (LVOs).1 Subsequent randomized trials not only confirmed the initial findings but also provided new evidence for the extension of the therapeutic time window emphasizing individual patients’ collateral vessels status and penumbra tissue-related factors.2 Nevertheless, a number of issues related to the practice of EVT remain open. Here, we provide a brief review of some of these issues and discuss their clinical implications.

Logistics of acute stroke interventions

Current situation in Europe

The situation in Europe in 2018 (i.e. 3 years after the new guidelines set thrombectomy as Class I.A indication) was described by the European Stroke Organization (ESO) survey.3 These data suggest that thrombectomy is performed in approximately one-third of patients, who (at least theoretically) should be treated by this method.

Importance of multidisciplinary cooperation, two levels of neurointerventional centres, involvement of interventional cardiologists

Unlike myocardial infarction (where a single specialist—interventional cardiologist is needed to manage the first in-hospital hour of STEMI)—for treatment of patients with acute ischaemic strokes (AIS) interdisciplinary stroke teams available 24 h/7 days are required.

The ESC Council on Stroke since its foundation in 2016 is continuously recommending the involvement of interventional cardiologists in the treatment of acute stroke in those countries or regions where neuro-interventionalists are not able to cover 24/7 thrombectomy services.4 Involving properly trained interventional cardiologists along with establishing the required logistics would allow upgrading Level 3 to Level 2 stroke centres improving EVT availability across Europe.