Perspectives in Medicine (2012) 1, 5458

Bartels E, Bartels S, Poppert H (Editors):

New Trends in Neurosonology and Cerebral Hemodynamics an Update.
Perspectives in Medicine (2012) 1, 5458

journal homepage: www.elsevier.com/locate/permed

Mechanical recanalization in acute stroke treatment

Pasquale Mordasini, Gerhard Schroth, Jan Gralla

Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Switzerland

KEYWORDS Summary Endovascular stroke treatment is a rapidly evolving eld in neurointerventions. The
article reviews the evolution of the different mechanical thrombolysis and stenting techniques
Mechanical
and their working principles for endovascular vessel recanalization and reviews the data on the
recanalization;
outcome after acute stroke treatment.
Mechanical
2012 Elsevier GmbH. Open access under CC BY-NC-ND license.
thrombectomy;
Endovascular stroke
treatment;
Acute stroke
treatment

Introduction methods are limited [24]. Furthermore, the application of

Ischemic stroke is one of the leading causes of disability
and mortality in industrialized countries. Patient outcome
mainly depends on the time span between onset of symp-
toms and revascularization, recanalization rate and the
occurrence of symptomatic intracranial hemorrhage (sICH)
[1]. Therefore, fast and effective reperfusion in combi-
nation with a low rate of sICH is the key to successful
stroke treatment. Systemic thrombolysis with intravenously
administered tissue plasminogen activator (IV rtPA) and local
intra-arterial thrombolysis (IAT) have been shown to be
effective to improve patient outcome. However, the time
window for treatment and the recanalization rate of both
Abbreviations: sICH, symptomatic intracranial hemorrhage; IV
rtPA, intravenously administered tissue plasminogen activator; IAT,
local intra-arterial thrombolysis; PTA, percutaneous angioplasty;
NIHSS, National Institute of Health Stroke Scale; FDA, Food and Drug
Administration.
Corresponding author at: Department of Diagnostic and
thrombolytic drugs increases the risk of sICH [5]. Moreover,
recanalization rate is dependent on the site of occlusion:
proximal occlusions of large brain supplying vessels such
as the internal carotid artery have a limited recanalization
rate after either IV rtPA or IAT [3,4]. Therefore, the aim of
mechanical recanalization approaches is to improve recanal-
ization rates, reduce the time to recanalization and further
expand the window of opportunity. Furthermore, the waiv-
ing of thrombolytic drugs is considered to reduce the rate
of symptomatic intracranial hemorrhage.
Mechanical treatment approaches
Different techniques and approaches have been advocated
for mechanical thrombolysis in acute stroke treatment,
which can be divided into: immediate ow restoration using
self-expandable stents and thrombectomy.
Stent recanalization

Interventional Neuroradiology, Inselspital, University of Bern, Placement of a permanent intracranial stent achieves imme-
Freiburgstrasse 4, CH-3010 Bern, Switzerland. diate ow restoration and recanalization by compressing
Tel.: +41 031 6322655; fax: +41 031 6324872. the thrombus against the vessel wall. Stenting allows fast
E-mail address: jan.gralla@insel.ch (J. Gralla). and effective recanalization without the need of repetitive

2211-968X 2012 Elsevier GmbH. Open access under CC BY-NC-ND license.

http://dx.doi.org/10.1016/j.permed.2012.04.004
Mechanical recanalization
passing of the occlusion site and retrieval attempts. How-
ever, this concept has some disadvantages in general and
especially in the setting of acute stroke treatment. Throm-
bus compression may lead to permanent side branch or
perforator occlusion. Moreover, permanent stent placement
needs double platelet anti-aggregation medication in order
to prevent in-stent thrombosis and re-occlusion. This pre-
ventive medication may increase the risk of sICH in the
setting of acute stroke [6]. Furthermore, an in-stent re-
stenosis rate of bare metal stents has been reported in
up to 32% in the treatment of intracranial arteriosclerotic
stenosis after a follow-up period of 9 months [7]. The
use of different stent systems has been reported in case
reports and small case series. In general, self-expandable
stents are preferentially used over balloon-mounted
stents.
Recanalization rates are reported to be between 79%
and 92% with moderate clinical outcome in 3350% [8,9].
The Stent-Assisted Recanalization in Acute Ischemic Stroke
(SARIS) trial is the rst FDA approved prospective trial inves-
tigating stenting in acute stroke treatment. 20 patients
(mean NIHSS 14) were included within 6 h after symptom
onset. Recanalization rate was 100% with adjuvant thera-
pies such as angioplasty, IV tPA and IAT applied in 63% of
patients. Moderate clinical outcome was achieved in 60% of
patients [10,11].
Despite the high recanalization rate reported in these
studies, the use of intracranial stenting in acute stroke
treatment is debatable due to the risks associated with
permanent stent deployment and the recent success of
thrombectomy. However, stenting has a clear value in selec-
tive cases of rescue therapy.
Mechanical thrombectomy
All mechanical thrombectomy devices are delivered by
endovascular access proximal to the occlusion site. The var-
ious systems can be divided into 3 major groups according
to where they apply mechanical force on the thrombus:
(a) Proximal devices apply force to the proximal base of
the thrombus. This group includes various aspiration
catheters and systems.
(b) Distal devices approach the thrombus proximally but
then are advanced by microguidewire and micro-
catheter across the thrombus to be unsheathed behind
it, where force is applied to the distal base of the
thrombus. This group includes brush-like, basket-like or
coil-like devices.
(c) The most recently developed devices include stent-like
devices, which are placed across the thrombus at the
occlusion site, deployed within the thrombus and then
are retrieved. This group includes various types of self-
expandable, retrievable, stent-like devices, so-called
stent retrievers.
Proximal thrombectomy using thrombus aspiration
Vascular access is usually gained with a 78-F sheath. After
placement of the guiding catheter, a large dedicated aspira-
tion catheter (45-F) exible enough to pass the tortuosity
of the cranial vessels (e.g. carotid siphon) is navigated to
55
the proximal surface of the thrombus. Aspiration force is
applied to the thrombus using a 60-ml syringe. The aspi-
ration catheter is then retrieved under constant negative
pressure to avoid loss of thrombus material. This approach
omits repetitive passing of the occlusion site and after each
retrieval of clot fragments, the procedure can be repeated.
The advantages of this approach are that it is mechanically
simple, fast to apply and inexpensive. Therefore, it is widely
used, especially in proximal occlusions when the target ves-
sel has a large diameter and an anatomy favorable for device
navigation such as the distal cervical internal carotid artery
and the carotid artery terminus. Although rst reports on
mechanical thrombectomy included the use of aspiration
catheters [12,13], only few systematic data have been pub-
lished on this approach so far. A recent single-center study
reported on 22 patients (mean NIHSS 18) treated with aspira-
tion thrombectomy alone with a recanalization rate of 81.9%
and a good clinical outcome in 45.5% [14].
Penumbra System. The Penumbra System (Penumbra,
Almeda, USA) is a modication of the proximal aspiration
technique. It has been FDA approved for clot removal in
acute stroke treatment in 2007. It consists of a reperfusion
catheter attached to continuous aspiration via a dedicated
pumping system. A microwire with an olive-shaped tip,
called separator, is used to fragmentize the thrombus from
proximal to distal and to avoid obstruction of the aspiration
catheter by cleaning the catheter tip of clot fragments. Both
reperfusion catheter and separator are available in various
sizes and diameters (0.260.51 in.) to adjust the device to
different anatomical settings and to allow thrombectomy
even in distal branches such as M2 segments.
The Penumbra System has been investigated in several
single-center and multicenter trials. The Penumbra Pivotal
Stroke Trial [15] prospectively evaluated 125 stroke patients
(mean NIHSS 18) within 8 h after onset of symptoms. Suc-
cessful recanalization of the target vessel was achieved in
81.6%. Despite the relatively high recanalization rate, favor-
able clinical outcome was achieved in only 25% of all patients
and in 29% of patients with successful recanalization. Overall
mortality was 32.8% and sICH occurred in 11.2% with serious
adverse events in 3.2%. The high recanalization rate in con-
junction with the poor clinical outcome in this trial sparked
the discussion on the impact of recanalization using mechan-
ical thrombectomy. However, some single-center studies
reported more favorable clinical results with the Penumbra
System and then the Pivotal Trial with successful recanal-
ization in 93%, good clinical outcome in 48% and reduced
mortality of 11% [16].
Distal thrombectomy
Compared to IAT and the use of proximal devices, the use
of distal thrombectomy devices is technically more com-
plex. An 8 F sheath and balloon catheter of similar size are
used. After placement of the balloon catheter in the internal
carotid artery, a microcatheter (0.180.27 in.) is navigated
across the occlusion site to pass the thrombus. The device
is then introduced into the microcatheter and unsheathed
behind the thrombus. This approach applies the retrieval
force to the distal base of the thrombus. The device and
thrombus are then retracted into the guide catheter under
balloon occlusion and additional aspiration.
56 P. Mordasini et al.

Figure 1 74-year-old male patient 4.5 h after acute onset of right hemiplegia and aphasia, at admission NIHSS 18, bridging therapy.
(A) Digital subtraction angiogram of the left internal carotid artery, illustrating proximal occlusion (arrow) of the middle cerebral
artery (MCA). (B) Application of a stent-retriever: a microcatheter and microwire are advanced beyond the occlusion side (arrow)
and placed into the distal branches of the MCA (*). (C) Angiogram immediately after placement of a stent-retriever (Solitaire
FR) covering the occlusion (arrow). The device compresses the thrombus and creates a channel; a temporary bypass to the distal
branches of the MCA (*). (D) After retrieval of the device 5 min later complete recanalization of the MCA main trunk (arrow) and
the distal braches. (E) The stent-retriever device (arrow) after the successful thrombectomy with the entangled clot from the MCA
(*). The patient recovered to NIHSS 5 after 24 h, mRS 1 after 90 days.

Clinical observations have shown that thrombectomy
using distal devices has the risk of potentially dislodging
thrombotic material during retrieval from the occlusion site
into a previously unaffected vascular territory. Such embolic
events may worsen the patients neurological condition.
Therefore, distal thrombectomy devices are regularly used
in combination with proximal balloon occlusion in the inter-
nal carotid artery in conjunction with aspiration from the
guiding catheter in order to reduce the risk of thromboem-
bolic events during retrieval. Furthermore, vasospasm and
vessel wall damage have been reported more frequently in
association with distal thrombectomy devices. Various distal
thrombectomy devices with brush-like, basket-like or coil-
like designs have been advocated in the past (e.g. Catch,
Balt, Montmorency, France; Phenox pCR and CRC, Bochum,
Germany), with most of them only available in Europe. The
largest clinical experience has been reported on the Merci
Retrieval System (Concentric Medical, Mountain View, USA),
which is the rst device of this group to receive FDA approval
in 2004.
Merci Retrieval System. The Merci Retrieval System is
somehow the pioneer of intracranial device development
for acute stroke treatment. FDA approval was based on the
multicenter Mechanical Embolus Removal in Cerebral
Ischemia (MERCI) trial [17]. 151 patients (mean NIHSS 20)
were evaluated within 8 h after onset of symptoms, who
were ineligible for standard IAT. Successful recanalization
was achieved in 46% of patients with favorable clinical out-
come in 27.7%. Mean procedure time was 2.1 h. Clinically
signicant procedural complications occurred in 7.1% and
rate of sICH was 7.8%. The Multi-MERCI trial [18] was a
prospective, multicenter, single-arm registry that included
164 patients (mean NIHSS 19) within 8 h after onset of symp-
toms. In contrast to the MERCI trial, patients with persistent
large vessel occlusion after IV tPA were also included in the
study, adjunctive IAT using rtPA and the use of other mechan-
ical recanalization techniques and new generation of Merci
devices were allowed. Recanalization success was 57.3%
using the Merci device alone and 69.5% in conjunction with
other treatment modalities. Favorable clinical outcome was
achieved in 36% of patients with clinical signicant compli-
cations in 5.5% and sICH in 9.8%. Mean time to recanalization
was 1.6 h.
The introduction of the Merci device was a landmark
of mechanical recanalization in acute stroke treat-
ment. Both MERCI trials demonstrated a signicantly
Mechanical recanalization
better clinical outcome in patients with successful recanal-
ization.
Stent retriever. The most recent developments for
mechanical acute stroke treatment are self-expandable,
retrievable, stent-like thrombectomy devices. They com-
bine the advantages of intracranial stent placement with
immediate ow restoration without the need of permanent
device implantation and the advantages of a thrombectomy
system with the ability of denitive clot removal. This con-
cept offers a promising new treatment option for acute
ischemic stroke with high recanalization rates, marked
reduction in procedure time and a marked elevation in
the rate of favorable clinical outcome. Stent retrievers are
applied in a comparable manner to that of intracranial
stents. The occlusion site is passed with a microcatheter
(0.210.27 in.) and the device is deployed over the entire
thrombus. Due to its radial force, the device compresses
the thrombus against the contralateral vessel wall leading
to immediate partial ow restoration to the distal vessel
territory. After an embedding time of 310 min the device
is retrieved. As for distal thrombectomy devices the use of
proximal balloon occlusion and aspiration during retrieval is
recommended in order to avoid thromboembolic events.
Several stent retrievers with different designs are cur-
rently under development or evaluated in rst clinical trials
(Trevo, Concentric Medical, Mountain View, USA; PULSE and
3D Separator, Penumbra, Almeda, USA; Revive, Micrus, USA;
Aperio, Acandis, Pforzheim, Germany; Bonnet and pREset,
Phenox, Bochum, Germany).
The rst dedicated combined ow restoration and
thrombectomy device for acute stroke treatment was the
Solitaire FR (ev3, Irvine, USA). The device is a modica-
tion of the Solitaire AB Neurovascular Remodeling Device,
originally developed for stent-assisted coil treatment of
wide-necked intracranial aneurysms. Within a short period
of time several in vivo and clinical studies have reported
about the application of the Solitaire FR for acute stroke
treatment (Fig. 1).
The rst clinical experience was published by Castano
et al. [19] in 2010 reporting their initial treatment of 20
patients within 8 h after onset of symptoms. Successful
recanalization was achieved in 90% of patients with a favor-
able clinical outcome in 45%. Mean procedure time was
short with 50 min. sICH occurred in 10%. Several other small
case series using various stent retrievers have shown simi-
lar promising successful recanalization rates (8891%) and
fast procedural times (4255 min) with comparable rates of
favorable clinical outcome (4254%) [2022]. Rohde et al.
[23] reported their preliminary experience with the Revive
system (Micrus Endovascular, San Jose, USA) in the treat-
ment of large vessel occlusion in 10 patients (mean NIHSS
19). The design of the Revive system consists of a closed
basket at the distal end of the stent in order to enhance
clot removal. Successful recanalization (TICI 2b or 3) was
achieved in all patients with favorable outcome in 60% of
patients after 30 days. The Solitaire FR with the Intention
for Thrombectomy (SWIFT) trial is a randomized trial com-
paring the efcacy and safety of the Solitaire FR with that
of the Merci device. The SWIFT trial was halted by the data
monitoring board early in 2011 after inclusion of 126 patients
of anticipated 250 patients. The results have not yet been
published, but favorable results for the Solitaire FR can be
57
assumed. The Solitaire FR is currently evaluated in the Soli-
taire FR Thrombectomy for Acute Revascularization (STAR)
trial, a prospective, multicenter, single-arm study with an
enrolment goal of 200 patients. The study includes patients
within 8 h after symptom onset ineligible for or with failed
IV rtPA as a bridging therapy or thrombectomy as initial
treatment. First results are expected in mid-2012.
Conclusion
Immediate ow restoration is the principle goal of ischemic
stroke therapy and is associated with better clinical out-
come and reduced mortality. The introduction of mechanical
approaches has expanded the time window for stroke treat-
ment and broadened the spectrum of stroke patients for
treatment. The latest results of MT using stent-retrievers
demonstrate high recanalization rates in conjunction with
short recanalization times and a low-risk device-related
severe adverse event. Furthermore, recent data show that
the increased recanalization rate of MT improves clinical
outcome.
The future role of MT in acute stroke treatment is not
clear yet. Considering the poor recanalization rate and clin-
ical outcome of patients with proximal vessel occlusions and
large thrombus burden (e.g. internal carotid artery occlu-
sion), MT is likely to become a rst-line treatment.
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