Endovascular clot retrieval (ECR)

Changed by Tristan Skalina, 25 Apr 2019

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Mechanical thrombectomy for acute ischaemic stroke is the endovascular retrieval of clots obstructing large intracranial vessels in acute ischaemic stroke patients.

History

In 2015, multiple randomized controlled trials showed improved clinical outcome in patients with acute stroke due to large vessel occlusion undergoing thrombectomy compared to medical (conservative) treatment alone ^3-5.

Indications

acute ischaemic stroke due to large vessel occlusion in the anterior circulation within 6 hours of symptom onset
as of 2017, several trials are underway to determine whether selected patient groups who fall outside the 6 hour time window may also benefit from thrombectomy ^6,7,11

Contraindications

Procedure

Preprocedural evaluation

Non-contrast enhanced CT is used to exclude haemorrhage and CT angiography to determine large vessel occlusion. Alternatively, MRI and DSA may also demonstrate the occlusion. Angiographic imaging can also assess collateral vessels which contribute to predicting outcome in some settings ⁸. The role of advanced imaging such as CT perfusion to determine the infarct core and penumbra size is still uncertain ¹⁰, yet the technique is being ushered into more and more centres based on international guidelines ¹¹.

Positioning/room set up

Equipment

stent retrievers
aspiration devices
balloon guiding catheter
microcatheters

Technique

{{youtube:http://www.youtube.com/watch?v=wY3fMI7LcCY&feature=c4-overview&list=UUU84jkgqGncjlV5YTKIFMow}}

Postprocedural care

Complications

The overall complication rate is about 15% ¹. Complications include ^2,9:

intracranial haemorrhage (<8%)
- parenchymal (5%)
- subarachnoid
emboli to new territories
vessel perforation (1 - 5%)
arterial dissection
vasospasm
vascular access site complications
- groin haematoma (2 - 11%)
- retroperitoneal haematoma (<6%)
mortality

Outcomes

The technical outcome is graded using the mTICI score. Thrombectomy is a highly effective treatment for stroke with a number needed to treat (NTT) of 2.6 for an improved functional outcome. In a meta-analysis, 46% of patients treated with mechanical thrombectomy achieved functional independence (modified Rankin scale (mRS) 0–2 at 90 days) compared to 27% for best medical treatment ².

~~-<li>as of 2017, several trials are underway to determine whether selected patient groups who fall outside the 6 hour time window may also benefit from thrombectomy <sup>6,7</sup>~~
+<li>as of 2017, several trials are underway to determine whether selected patient groups who fall outside the 6 hour time window may also benefit from thrombectomy <sup>6,7,11</sup>
-</ul><h4>Contraindications</h4><h4>Procedure</h4><h5>Preprocedural evaluation</h5><p>Non-contrast enhanced CT is used to exclude haemorrhage and CT angiography to determine large vessel occlusion. Alternatively, MRI and DSA may also demonstrate the occlusion. Angiographic imaging can also assess collateral vessels which contribute to predicting outcome in some settings <sup>8</sup>. The role of advanced imaging such as <a href="/articles/ct-perfusion-in-ischaemic-stroke">CT perfusion</a> to determine the <a href="/articles/infarct-core">infarct core</a> and <a href="/articles/ischaemic-penumbra">penumbra</a> size is still uncertain <sup>10</sup>, yet the technique is being ushered into more and more centres.</p><h5>Positioning/room set up</h5><h5>Equipment</h5><ul>
+</ul><h4>Contraindications</h4><h4>Procedure</h4><h5>Preprocedural evaluation</h5><p>Non-contrast enhanced CT is used to exclude haemorrhage and CT angiography to determine large vessel occlusion. Alternatively, MRI and DSA may also demonstrate the occlusion. Angiographic imaging can also assess collateral vessels which contribute to predicting outcome in some settings <sup>8</sup>. The role of advanced imaging such as <a href="/articles/ct-perfusion-in-ischaemic-stroke">CT perfusion</a> to determine the <a href="/articles/infarct-core">infarct core</a> and <a href="/articles/ischaemic-penumbra">penumbra</a> size is still uncertain <sup>10</sup>, yet the technique is being ushered into more and more centres based on international guidelines <sup>11</sup>.</p><h5>Positioning/room set up</h5><h5>Equipment</h5><ul>

References changed:

11. Powers W, Rabinstein A, Ackerson T et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46-e110. <a href="https://doi.org/10.1161/STR.0000000000000158">doi:10.1161/STR.0000000000000158</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/29367334">Pubmed</a>

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