Advances in Revascularization for Acute Ischemic Stroke Treatment

An Update

Muneer Eesa; Hermann Christian Schumacher; Randall T Higashida; Philip M Meyers

Disclosures

Expert Rev Neurother. 2011;11(8):1125-1139. 

In This Article

Aspiration Thrombectomy

Aspiration thrombectomy has been used for recanalization of occluded basilar[78,79] and extracranial internal carotid arteries.[80] In suction thrombectomy, the catheter tip is placed immediately proximal to the clot and negative pressure is applied at the distal catheter opening by suctioning through a 50 or 60 ml syringe through the proximal catheter port. This results in clot aspiration into the catheter. In cases with a large clot burden or highly organized clots, the catheter and attached clot are removed together. If successful, suction thrombectomy may lead to immediate recanalization of the occluded artery (Figure 4). An advantage of this technique is that it utilizes widely available endovascular equipment and may cause fewer embolic events and vasospasm. However, it requires the navigation of fairly large-diameter catheters (4F–7F), which may be difficult to navigate into the tortuous intracranial arteries.

Figure 4.

Aspiration thrombectomy with the Penumbra Stroke System® (Penumbra, CA, USA): 72-year-old right-handed woman with known atrial fibrillation developed sudden left hemiplegia and neglect with a fixed right gaze deviation. (A) Axial maximal intensity projection of a computed tomography angiogram obtained emergently shows occlusion at the level of the right M1 middle cerebral artery (white arrowhead). (B) Frontal projection of a right common carotid angiogram confirms the occlusion (black arrowhead). (C) Fluoroscopic image shows the 0.054 inch Penumbra reperfusion catheter at the level of the thrombus. Note the separator within the distal marker of the reperfusion catheter. (D) Final control angiogram demonstrates Thrombolysis In Myocardial Infarction 3 flow to the right middle cerebral artery branches.

The new Penumbra Stroke System® (Penumbra, CA, USA) has been specifically designed for aspiration thrombectomy in the distal intracranial vasculature. The original system included two different revascularization options. The first option consisted of a reperfusion catheter that aspirates the thrombus, while the separator device macerates clots and prevents the clots from obstructing the catheter. The second revascularization option included a direct thrombus extractor using a ring-retriever device, while a balloon-guide catheter is used for flow arrest. The system was tested in a pilot study in which 23 patients at six international centers were enrolled.[81] Three enrolled subjects were not treated due to vessel tortuosity. Recanalization before IAT was achieved in all treated cases (48% TIMI 2 and 52% TIMI 3). Six patients were refractory to intravenous tPA and nine patients received intra-arterial tPA after device deployment. Good outcome at 90 days (mRS ≤2, NIHSS improved by 4 points) was demonstrated in 45% of patients. The mortality rate was 45%. There were eight cases of ICH, of which two were symptomatic.

This study was followed by a larger prospective single-arm, multicenter trial, the Penumbra Pivotal Stroke Trial.[82] The study was conducted at centers in the USA and Europe. A total of 125 patients were enrolled (mean age 63.5 ± 13.5 years; baseline NIHSS 17.3 ± 5.2). Complete or partial recanalization (TIMI 2–3) was seen in 81.6% cases. Symptomatic ICH occurred in 14 out of 125 patients (11.2%) and asymptomatic ICH in 21 patients (16.8%). At discharge, 57.8% of patients achieved ≥4-point improvement in the NIHSS score and 25% of patients had mRS ≤2 at 90 days. Based on the results of the Penumbra pivotal stroke trial, the FDA approved the use of the thrombus aspiration device for clot removal in acute patients with stroke (Figure 4).

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