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EDITORIAL COMMENTARY
Year : 2022  |  Volume : 25  |  Issue : 2  |  Page : 184
 

Mechanical thrombectomy- Where do we stand now ?


Department of Neurology, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India

Date of Submission18-Mar-2022
Date of Acceptance19-Mar-2022
Date of Web Publication25-May-2022

Correspondence Address:
Debabrata Chakraborty
64/4A/9, Beliaghata Main Road, Kolkata–700 010, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aian.aian_263_22

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How to cite this article:
Chakraborty D, Bhaumik S. Mechanical thrombectomy- Where do we stand now ?. Ann Indian Acad Neurol 2022;25:184

How to cite this URL:
Chakraborty D, Bhaumik S. Mechanical thrombectomy- Where do we stand now ?. Ann Indian Acad Neurol [serial online] 2022 [cited 2022 Jul 1];25:184. Available from: https://www.annalsofian.org/text.asp?2022/25/2/184/345412




With advancement of radiological evaluation, more significant number of patients with acute stroke is noted to have large vessel stenosis or occlusion. The success of thrombolysis ranges from 8.7% to 65.9% depending on the vessel involved.[1] So, endovascular catheter-based approaches to achieve recanalization using mechanical clot disruption or by locally injected thrombolytic agents or both are the next options. Direct intra-arterial therapy (without thrombolysis for patients within time-window for same) is also the only way out in selective patients who have absolute contraindication(s) for receiving thrombolysis and have target vessel. The outcome depends on the timing of presentation, as earlier presentation in the time-window is related to better outcome.

Mechanical thrombectomy is gaining more and more ground with advancement of the devices. The clot retrieval is becoming more efficacious and distal vessels are getting more successfully reachable. However, as rightly hinted in the article,[2] we need to have more randomized control trials on intra-arterial thrombolysis before we can confidently comment on its efficacy and current status. This is because unlike pro-urokinase, which was used in PROACT II trial (1999), we have now more potent thrombolytic agent like Tenecteplase and Alteplase with a better safety profile. The intra-arterial thrombolytic agent poses less chance of systemic complication and will be better acceptable in patients with coagulation disorder (as it utilizes more targeted approach with a lesser amount of the drug). As per ESO guideline 2021, Tenecteplase is preferred over Alteplase in thrombolysis with large vessel occlusion in whom mechanical thrombectomy is decided as part of treatment.[3] This shows that the thrombolytic agents with advancement will be more suitable and outcome of intra-arterial therapy will be comparable to mechanical thrombectomy in acute stroke management.

Wake up strokes comprise almost one in five ischemic strokes[4] and the role of CT and MR perfusion is important in these cases. After the DEFUSE 3 and DAWN trial, the option of mechanical thrombectomy has extended further. With the advancement of software, the detection of diffusion-perfusion mismatch is possible and more patients can be given the benefit of mechanical thrombectomy. It is now when “time window” is getting changed to “tissue window.”

However, everyone (including family of patient) should accept limitations of this high-end procedure. It is costlier on one hand and can only be performed at the comprehensive stroke center. So, availability of Cath lab and trained staff is of utmost necessity for the success. Even then, the eventual outcome is not guaranteed! It depends on time of presentation (every 30-min delay in MT decreases favorable outcomes by 11%)[5]; site of occlusion/stenosis, nature of clot, collateral status, and, of course, systemic comorbidities.

Mechanical thrombectomy reduces mortality in three months by 17% in acute ischemic stroke patients with large vessel occlusion.[6] It should be performed in 31 acute ischemic stroke patients with large vessel occlusion to save the life of one more patient.[6] The emergency team and whole supporting staff should understand the urgency and act accordingly. The family of the patient should appreciate the brave and well-recognised attempt and learn to accept a failure (if happens by chance!).

Clearly, to the best of our knowledge, the current manuscript is an excellent review of the procedure (mechanical thrombectomy in acute stroke). It has included every concerned detail.

The outcome will be better if more public awareness program about details of the procedure is implemented. The family should be well informed (maybe through an App) about the nearest stroke ready center so that minimum time is lost while dealing with acute stroke patients. Hospital staff should be alarmed in acute stroke setting so that in house stroke is also not missed.



 
   References Top

1.
del Zoppo GJ, Poeck K, Pessin MS, Wolpert SM, Furlan AJ, Ferbert A, et al. Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke. Ann Neurol 1992;32:78-86.  Back to cited text no. 1
    
2.
Mechanical thrombectomy- review : This is the manuscript on which the editorial commentary is based.  Back to cited text no. 2
    
3.
Berge E, Whiteley W, Audebert H, De Marchis GM, Fonseca AC, Padiglioni C, et al. European stroke organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J 2021;6:I-LXII.  Back to cited text no. 3
    
4.
Rubin MN, Barrett KM. What to do with wake-up stroke. Neurohospitalist 2015;5:161-72.  Back to cited text no. 4
    
5.
Katz BS, Adeoye O, Sucharew H, Broderick JP, McMullan J, Khatri P, et al. Estimated impact of emergency medical service triage of stroke patients on comprehensive stroke centers. Stroke 2017;48:2164-70.  Back to cited text no. 5
    
6.
Katsanos AH, Malhotra K, Goyal N, Palaiodimou L, Schellinger PD, Caso V, et al. Mortality risk in acute ischemic stroke patients with large vessel occlusion treated with mechanical thrombectomy. J Am Heart Assoc 2019;8:e014425.  Back to cited text no. 6
    




 

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