Which Patients Qualify for Thrombectomy in Large Vessel Stroke?

Mark J. Alberts, MD


August 30, 2019

This transcript has been edited for clarity.

Hello and welcome. I'm Dr Mark Alberts, physician-in-chief of the Ayer Neuroscience Institute, which is part of Hartford HealthCare. Thanks for joining us.

I'm doing this Medscape update from the American Academy of Neurology Annual Meeting in Philadelphia. Great science and great studies have been presented at this meeting, including a number of studies looking at this issue of large vessel occlusion in terms of patient selection and treatment with thrombectomy.

This is a growing area and it's a great opportunity because, with the results of DAWN, DEFUSE 3, and other subsequent studies, we now know that with careful imaging tools, we can do a very good job of selecting patients up to 24 hours after stroke onset.[1,2]

We also know that these patients benefit from treatment when it's done using some of our new devices, and especially when it's done by a well-trained and coordinated team of neurologists, neurosurgeons, and interventional cardiologists.

One of the hot topics is improving our selection of patients for endovascular therapy and thrombectomy. How big of a core should the patient have or not have so that they have a good outcome? How large should their ischemic penumbra be so that they have the chance of better outcome? Regarding new devices for clot removal, how safe can they be to prevent reperfusion injury?

Those were some of the studies presented at this meeting. What's clear from a growing body of work is that this ability to intervene in patients with large vessel stroke has almost been a revolution.

One of the areas that is still unclear and continues to evolve is the selection of these patients in the field. When EMS goes to pick them up, they may know the patient has a large deficit, but they may not know the type of stroke—ischemic or hemorrhagic—and they may not know if the patient will benefit from endovascular therapy.

In the field, various scales that have been used to identify these patients and select patients who are more or less likely to benefit have not really been proven. We know that some systems are using mobile stroke units with a CT scanner in the ambulance to try to rule out hemorrhagic stroke. However, they cannot necessarily figure out who has a salvageable penumbra and may benefit from endovascular therapy.

Stroke systems of care are evolving with various tools to try to figure out which patients need to go to a comprehensive stroke center and which patients can go to a primary stroke center or another type of hospital.

This is very much a work in evolution, and we hope that there will be more positive results to report to you in the future.

Thank you very much for tuning in. This is Mark Alberts from Medscape, reporting from the American Academy of Neurology Annual Meeting in Philadelphia. Have a great day.

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