Endovascular Treatment of an Ischemic Cerebrovascular Event

Authors: D. Školoudík 1,2;  M. Kuliha 1,2;  T. Jonszta 3;  R. Herzig 1
Authors‘ workplace: Komplexní cerebrovaskulární centrum, Neurologická klinika LF UP a FN Olomouc 1;  Komplexní cerebrovaskulární cen­trum, Neurologická klinika FN Ostrava 2;  Komplexní cerebrovaskulární cen­trum, Radiologická klinika FN Ostrava 3
Published in: Cesk Slov Neurol N 2012; 75/108(6): 669-683
Category: Minimonography


Stroke is one of the most frequent causes of mortality, morbidity and disability worldwide, especially in developed countries. Acute occlusion of cerebral artery, detectable during the first hours after an onset of symptoms in more than 70% of patients, is the most common cause of acute ischemic stroke. Early recanalization of cerebral artery is associated with a higher chance for independency after three months and lower mortality. In addition to pharmacological methods (systemic, local and combined thrombolysis), endovascular mechanical methods to accelerate recanalization of occluded cerebral arteries are being tested. The paper describes various endovascular instruments and results of studies conducted so far. Results from initial studies showed mechanical devices to be safe and effective with increasing proportion of successful recanalizations and relatively low risk of both periprocedural complications and symptomatic intracranial bleeding. At present, mechanical recanalization methods are indicated especially in patients with acute occlusion of intracranial artery and intravenous thrombolysis failure or contraindication.

Key words:
acute stroke – treatment – endovascular procedures – retrievers – stents


1. Feigin VL, Lawes CM, Bennett DA, Anderson CS. Stroke epidemiology: a review of population-based studies of incidence prevalence and case-fatality in the late 20th century. Lancet Neurol 2003; 2(1): 43–53.

2. Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N et al. Heart disease and stroke statistics – 2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008; 117(4): e25–e146.

3. Truelsen T, Piechowski-Jóźwiak B, Bonita R, Mathers C, Bogousslavsky J, Boysen G. Stroke incidence and prevalence in Europe: a review of available data. Eur J Neurol 2006; 13(6): 581–598.

4. van der Worp HB, van Gijn J. Clinical practice. Acute ischemic stroke. N Engl J Med 2007; 357(6): 572–579.

5. Fieschi C, Argentino C, Lenzi GL, Sacchetti ML, Toni D, Bozzao L. Clinical and instrumental eva­luation of patients with ischemic stroke within the first six hours. J Neurol Sci 1989; 91(3): 311–321.

6. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 2007; 38(3): 967–973.

7. 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(24): 1581–1588.

8. Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D et al. ECASS 3 Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359(13): 1317–1329.

9. Külkens S, Hacke W. Thrombolysis with alteplase for acute ischemic stroke: review of SITS-MOST and other Phase IV studies. Expert Rev Neurother 2007; 7(7): 783–788.

10. Lee KY, Han SW, Kim SH, Nam HS, Ahn SW, Kim DJ et al. Early recanalization after intravenous administration of recombinant tissue plasminogen activator as assessed by pre- and post-thrombolytic angiography in acute ischemic stroke patients. Stroke 2007; 38(1): 192–193.

11. Jonszta T, Kuliha M, Roubec M, Herzig R, Šaňák D, Procházka V et al. Endovascular Treatment of Acute Ischemic Stroke. In: Sanders KI, Jackson AM (eds). New Developments in Angiography Research. New York: Nova Science Publishers. In press 2012.

12. Blakeley JO, Llinas RH. Thrombolytic therapy for acute ischemic stroke. J Neurol Sci 2007; 261(1–2): 55–62.

13. Brott T, Bogousslavsky J. Treatment of acute ischemic stroke. N Engl J Med 2000; 343(10): 710–722.

14. Ahmad A, Sharma VK. More on: optimal dose for stroke thrombolysis in Asians. J Thromb Haemost 2012; 10(9): 1970–1971.

15. Smith WS, Sung G, Starkman S, Saver JL, Kidwell CS, Gobin YP et al. MERCI Trial Investigators. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke 2005; 36(7): 1432–1440.

16. Chopko BW, Kerber C, Wong W, Georgy B. Trans­catheter snare removal of acute middle cerebral artery thromboembolism: technical case report. Neurosurgery 2000; 46(6): 1529–1531.

17. Kerber CW, Barr JD, Berger RM, Chopko BW. Snare retrieval of intracranial thrombus in patients with acute stroke. J Vasc Interv Radiol 2002; 13(12): 1269–1274.

18. Fourie P, Duncan IC. Microsnare-assisted mechanical removal of intraprocedural distal middle cerebral arterial thromboembolism. Am J Neuroradiol 2003; 24(4): 630–632.

19. Schumacher HC, Meyers PM, Yavagal DR, Harel NY, Elkind MS, Mohr JP et al. Endovascular mechanical thrombectomy of an occluded superior division branch of the left MCA for acute cardioembolic stroke. Cardiovasc Intervent Radiol 2003; 26(3): 305–308.

20. Baker WL, Colby JA, Tongbram V, Talati RA, Silverman IE, White CM et al. Neurothrombectomy Devices for Treatment of Acute Ischemic Stroke. Rockville (MD): Agency for Healthcare Research and Quality 2011.

21. Smith WS, Sung G, Starkman S, Saver JL, Kidwell CS, Gobin YP et al. MERCI Trial Investigators. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke 2005; 36(7): 1432–1438.

22. Josephson SA, Saver JL, Smith WS. Merci and Multi Merci Investigators. Comparison of mechanical embolectomy and intra-arterial thrombolysis in acute ischemic stroke within the MCA: MERCI and Multi MERCI compared to PROACT II. Neurocrit Care 2009; 10(1): 43–49.

23. Smith WS. Safety of mechanical thrombectomy and intravenous tissue plasminogen activator in acute ischemic stroke. Results of the multi Mechanical Embolus Removal in Cerebral Ischemia (MERCI) trial part I. AJNR Am J Neuroradiol 2006; 27(6): 1177–1182.

24. Smith WS, Sung G, Saver J, Budzik R, Duckwiler G, Liebeskind DS et al. Multi MERCI Investigators. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI Trial. Stroke 2008; 39(4): 1205–1212.

25. Nogueira RG, Smith WS, Sung G, Duckwiler G, Walker G, Roberts R et al. MERCI and Multi MERCI Writing Committee. Effect of time to reperfusion on clinical outcome of anterior circulation strokes treated with thrombectomy: pooled analysis of the MERCI and Multi MERCI trials. Stroke 2011; 42(11): 3144–3149.

26. Nogueira RG, Liebeskind DS, Sung G, Duckwiler G, Smith WS. Multi MERCI Writing Committee. 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(12): 3777–3783.

27. Shi ZS, Loh Y, Walker G, Duckwiler GR. MERCI and Multi MERCI Investigators. Clinical outcomes in middle cerebral artery trunk occlusions versus secondary division occlusions after mechanical thrombectomy: pooled analysis of the Mechanical Embolus Removal in Cerebral Ischemia (MERCI) and Multi MERCI trials. Stroke 2010; 41(5): 953–960.

28. Flint AC, Duckwiler GR, Budzik RF, Liebeskind DS, Smith WS. MERCI and Multi MERCI Writing Committee. Mechanical thrombectomy of intracranial internal carotid occlusion: pooled results of the MERCI and Multi MERCI Part I trials. Stroke 2007; 38(4): 1274–1280.

29. Lutsep HL, Rymer MM, Nesbit GM. Vertebrobasilar revascularization rates and outcomes in the MERCI and multi-MERCI trials. J Stroke Cerebrovasc Dis 2008; 17(2): 55–57.

30. Penumbra Pivotal Stroke Trial Investigators. 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(8): 2761–2768.

31. Saver JL, Liebeskind DS, Nogueira RG, Jahan R. Need to clarify Thrombolysis In Myocardial Ischemia (TIMI) scale scoring method in the Penumbra Pivotal Stroke Trial. Stroke 2010; 41(2): e115–e116.

32. Grunwald IQ, Wakhloo AK, Walter S, Molyneux AJ, Byrne JV, Nagel S et al. Endovascular stroke treatment today. AJNR Am J Neuroradiol 2011; 32(2): 238–243.

33. Castaño C, Dorado L, Guerrero C, Millán M, Gomis M, Perez de la Ossa N et al. Mechanical thrombectomy with the Solitaire AB device in large artery occlusions of the anterior circulation: a pilot study. Stroke 2010; 41(8): 1836–1840.

34. Machi P, Costalat V, Lobotesis K, Maldonado IL, Vendrell JF, Riquelme C et al. Solitaire FR thrombectomy system: immediate results in 56 consecutive acute ischemic stroke patients. J Neurointerv Surg 2012; 4(1): 62–66.

35. Roth C, Papanagiotou P, Behnke S, Walter S, Haass A, Becker C et al. Stent-assisted mechanical recanalization for treatment of acute intracerebral artery occlusions. Stroke 2010; 41(11): 2559–2567.

36. Seifert M, Ahlbrecht A, Dohmen C, Spuentrup E, Moeller-Hartmann W. Combined interventional stroke therapy using intracranial stent and local intra-arterial thrombolysis (LIT). Neuroradiology 2010; 53(4): 273–282.

37. Costalat V, Machi P, Lobotesis K, Maldonado I, Vendrell JF, Riquelme C et al. 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(7): 1929–1935.

38. Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA et al. TREVO 2 Trialist. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet 2012; 380(9849): 1231–1240.

39. Mendonça N, Flores A, Pagola J, Rubiera M, Rodríguez-Luna D, De Miquel MA et al. Trevo System: Single-Center Experience with a Novel Mechanical Thrombectomy Device. J Neuroimaging. In press 2011.

40. Mourand I, Brunel H, Costalat V, Riquelme C, Lobotesis K, Milhaud D et al. Mechanical thrombectomy in acute ischemic stroke: catch device. AJNR Am J Neuroradiol 2011; 32(8): 1381–1385.

41. Baker WL, Colby JA, Tongbram V, Talati R, Silverman IE, White CM et al. Neurothrombectomy devices for the treatment of acute ischemic stroke: state of the evidence. Ann Intern Med 2011; 154(4): 243–252.

42. Meyers PM, Schumacher HC, Connolly ES jr, Heyer EJ, Gray WA, Higashida RT. Current status of endovascular stroke treatment. Circulation 2011; 123(22): 2591–2601.

43. Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG et al. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel--group, non-inferiority trial. Lancet 2012; 380(9849): 1241–1249.

44. Thrombectomy Revascularization of Large Vessel Occlusion in Acute Ischemic Stroke (TREVO). Available from: http://clinicaltrials.gov/ct2/show/NCT01088672.

45. Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR-RESCUE). Available from: http://clinicaltrials.gov/ct2/show/NCT00389467.

46. DWI/PWI and CTP assessment in the triage of wake-up and late presenting strokes undergoing neurointervention (DAWN). Available from: http://www.strokecenter.org/trials/clinicalstudies/dwipwi-and-ctp-assessment-in-the-triage-of-wake-up-and-late-presenting-strokes-undergoing-neurointervention.

47. Samaniego EA, Dabusand G, Linfante I. Stenting in the treatment of acute ischemic stroke: literature review. Front Neurol 2011; 2: 76.

48. Roubec M, Kuliha M, Prochazka V, Krajca J, Czerny D, Jonszts T et al. A controlled trial of revascularization in acute stroke. Radiology. In press 2012.

49. Fitzsimmons BF, Becske T, Nelson PK. Rapid stent-supported revascularization in acute ischemic stroke. AJNR Am J Neuroradiol 2006; 27(5): 1132–1134.

50. Levy EI, Mehta R, Gupta R, Hanel RA, Chamczuk AJ, Fiorella D et al. Self-expanding stents for recanalization of acute cerebrovascular occlusions. AJNR Am J Neuroradiol 2007; 28(5): 816–822.

51. Zaidat OO, Wolfe T, Hussain SI, Lynch JR, Gupta R, Delap J et al. Interventional acute ischemic stroke therapy with intracranial self-expanding stent. Stroke 2008; 39(8): 2392–2395.

52. Brekenfeld C, Schroth G, Mattle HP, Do DD, Remonda L, Mordasini P et al. Stent placement in acute cerebral artery occlusion: use of a self-expandable intracranial stent for acute stroke treatment. Stroke 2009; 40(3): 847–852.

53. Mocco J, Hanel RA, Sharma J, Hauck EF, Snyder KV, Natarajan SK et al. Use of a vascular reconstruction device to salvage acute ischemic occlusions refractory to traditional endovascular recanalization methods. J Neurosurg 2010; 112(3): 557–562.

54. Suh SH, Kim BM, Roh HG, Lee KY, Park SI, Kim DI et al. Self-expanding stent for recanalization of acute embolic or dissecting intracranial artery occlusion. AJNR Am J Neuroradiol 2010; 31(3): 459–463.

55. Linfante I, Samaniego EA, Geisbüsch P, Dabus G. Self-expandable stents in the treatment of acute ischemic stroke refractory to current thrombectomy devices. Stroke 2011; 42(9): 2636–2638.

56. 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(12): 2872–2876.

57. Qureshi AI, Siddiqui AM, Suri MF, Kim SH, Ali Z, Yahia AM et al. Aggressive mechanical clot disruption and low-dose intra-arterial third-generation thrombolytic agent for ischemic stroke: a prospective study. Neurosurgery 2002; 51(5): 1319–1329.

58. Jovin TG, Gupta R, Uchino K, Jungreis CA, Wechsler LR, Hammer MD et al. Emergent stenting of extracranial internal carotid artery occlusion in acute stroke has a high revascularization rate. Stroke 2005; 36(11): 2426–2430.

59. Levy EI, Siddiqui AH, Crumlish A, Snyder KV, Hauck EF, Fiorella DJ 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(11): 3552–3556.

60. Levy EI, Rahman M, Khalessi AA, Beyer PT, Natarajan SK, Hartney ML et al. Midterm clinical and angiographic follow-up for the first Food and Drug Administration-approved prospective, Single-Arm Trial of Primary Stenting for Stroke: SARIS (Stent-Assisted Recanalization for Acute Ischemic Stroke). Neurosurgery 2011; 69(4): 915–920.

61. Francis CW, Blinc A, Lee S, Cox C. Ultrasound accelerates transport of recombinant tissue plasminogen activator into clots. Ultrasound Med Biol 1995; 21(3): 419–424.

62. Skoloudik D, Fadrna T, Roubec M, Bar M, Zapletal O, Blatny J et al. Changes in hemocoagulation in acute stroke patients after one-hour sono-thrombolysis using a diagnostic probe. Ultrasound Med Biol 2010; 36(7): 1052–1059.

63. Skoloudik D, Fadrna T, Bar M, Zapletalova O, Zapletal O, Blatny J et al. Changes in haemocoagulation in healthy volunteers after a 1-hour thrombotripsy using a diagnostic 2–4 MHz transcranial probe. J Thromb Thrombolysis 2008; 26(2): 119–124.

64. Suchkova VN, Baggs RB, Francis CW. Effect of 40-kHz ultrasound on acute thrombotic ischemia in a rabbit femoral artery thrombosis model: enhancement of thrombolysis and improvement in capillary muscle perfusion. Circulation 2000; 101(19): 2296–2301.

65. Bardon P, Skoloudik D, Langova K, Herzig R, Kanovský P. Changes in blood flow velocity in the radial artery during 1-hour ultrasound monitoring with a 2-MHz transcranial probe – a pilot study. J Clin Ultrasound 2010; 38(9): 493–496.

66. Harvey EN. Biological aspects of ultrasonic waves a general survey. Biol Bull 1930; 59(3): 306–325.

67. Mahon BR, Nesbit GM, Barnwell SL, Clark W, Marotta TR, Weill A et al. North American clinical expe­rience with the EKOS MicroLysUS infusion catheter for the treatment of embolic stroke. AJNR Am J Neuroradiol 2003; 24(3): 534–538.

68. IMS II Trial Investigators. The Interventional Management of Stroke (IMS) II Study. Stroke 2007; 38(7): 2127–2135.

69. Janjua N, Alkawi A, Suri MF, Qureshi AI. Impact of arterial reocclusion and distal fragmentation during thrombolysis among patients with acute ischemic stroke. AJNR Am J Neuroradiol 2008; 29(2): 253–258.

70. Nogueira RG, Yoo AJ, Buonanno FS, Hirsch JA. Endovascular approaches to acute stroke, part 2: a comprehensive review of studies and trials. AJNR Am J Neuroradiol 2009; 30(5): 859–875.

71. Tomsick T, Broderick J, Carrozella J, Khatri P, Hill M, Palesch Y et al. Interventional Management of Stroke II Investigators. Revascularization results in the Interventional Management of Stroke II trial. Am J Neuroradiol 2008; 29(3): 582–587.

72. Kuliha M, Roubec M, Jonszta T, Krajca J, Czerny D, Krajina A et al. Safety and efficacy of endovascular sonolysis using the EkoSonicTM endovascular system in acute stroke patients. Am J Neuroradiol. In press 2012.

73. Khatri P, Hill MD, Palesch YY, Spilker J, Jauch EC, Carrozzella JA et al. Interventional Management of Stroke III Investigators. Methodology of the Interventional Management of Stroke III Trial. Int J Stroke 2008; 3(2): 130–137.

74. Berlis A, Lutsep H, Barnwell S, Norbash A, Wechsler L, Jungreis CA et al. Mechanical thrombolysis in acute ischemic stroke with endovascular photoacoustic recanalization. Stroke 2004; 35(5): 1112–1116.

75. Rohde S, Haehnel S, Herweh C, Pham M, Stampfl S, Ringleb PA et al. Mechanical thrombectomy in acute embolic stroke: preliminary results with the revive device. Stroke 2011; 42(10): 2954–2956.

76. Gonzalez RG, Hirsch JA, Lev MH et al. Acute Ischemic Stroke: Imaging and Intervention. 2nd ed. Berlin: Springer-Verlag 2011.

77. Tomsick T. TIMI, TIBI, TICI: I came, I saw, I got confused. AJNR Am J Neuroradiol 2007; 28(2): 382–384.

78. Bar M, Mikulik R, Jonszta T, Krajina A, Roubec M, Skoloudik D et al. Diagnosis of recanalization of the intracranial artery has poor inter-rater reliability. AJNR Am J Neuroradiol 2012; 33(5): 972–974.

79. Wilson JT, Hareendran A, Hendry A, Potter J, Bone I, Muir KW. Reliability of the modified Rankin Scale across multiple raters: benefits of a structured interview. Stroke 2005; 36(4): 777–781.

80. Tomek A, Šaňák D, Šrámek M et al. Neurointenzivní péče. Praktická příručka. Praha: Mladá fronta 2012.

81. Higashida RT, Furlan AJ, Roberts H, Tomsick T, Connors B, Barr J et al. Technology Assessment Committee of the American Society of Interventional and Therapeutic Neuroradiology; Technology Assessment Committee of the Society of Interventional Radiology. Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke. Stroke 2003; 34(8): e109–e137.

82. Noser EA, Shaltoni HM, Hall CE, Alexandrov AV, Garami Y, Cacayorin ED et al. Aggressive mechanical clot disruption: a safe adjunct to thrombolytic therapy in acute stroke? Stroke 2005; 36(2): 292–296.

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