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Revolution in acute ischaemic stroke care: a practical guide to mechanical thrombectomy
  1. Matthew R B Evans1,
  2. Phil White2,
  3. Peter Cowley1,3,
  4. David J Werring1
  1. 1 Stroke Research Centre, Department of Brain repair and Rehabilitation, University College London Institute of Neurology, London, UK
  2. 2 Stroke Research Centre, Institute of Neuroscience and Newcastle University Institute for Ageing, Newcastle Upon Tyne, UK
  3. 3 Neuroradiological Academic Unit, University College London Institute of Neurology, London, UK
  1. Correspondence to Professor David J Werring, Stroke Research Centre, University College London Institute of Neurology, London, UK; d.werring{at}ucl.ac.uk

Abstract

Rapid, safe and effective arterial recanalisation to restore blood flow and improve functional outcome remains the primary goal of hyperacute ischaemic stroke management. The benefit of intravenous thrombolysis with recombinant tissue-type plasminogen activator for patients with severe stroke due to large artery occlusion is limited; early recanalisation is generally less than 30% for carotid, proximal middle cerebral artery or basilar artery occlusion. Since November 2014, nine positive randomised controlled trials of mechanical thrombectomy for large vessel occlusion in the anterior circulation have led to a revolution in the care of patients with acute ischaemic stroke. Its efficacy is unmatched by any previous therapy in stroke medicine, with a number needed to treat of less than 3 for improved functional outcome. With effectiveness shown beyond any reasonable doubt, the key challenge now is how to implement accessible, safe and effective mechanical thrombectomy services. This review aims to provide neurologists and other stroke physicians with a summary of the evidence base, a discussion of practical aspects of delivering the treatment and future challenges. We aim to give guidance on some of the areas not clearly described in the clinical trials (based on evidence where available, but if not, on our own experience and practice) and highlight areas of uncertainty requiring further research.

  • stroke
  • thrombolysis
  • mechanical
  • thrombectomy

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

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Footnotes

  • Contributors ME, PC, PW and DW wrote the manuscript and are responsible for the content.

  • Funding DW receives research funding support from the British Heart Foundation and the Stroke Association (TSA BHF 2009/01; PPA 2015/04). This work was undertaken at University College London Hospitals NHS Foundation Trust/University College London who received a proportion of funding from the Department of Health’s National Institute for Health Research Biomedical Research Centers funding scheme.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed. This paper was reviewed by William Whiteley, Edinburgh, UK.

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