Unresolved Issues in Thrombectomy

Trials demonstrating marked benefit of mechanical thrombectomy (MT) for acute stroke caused by large vessel occlusion (LVO) in the anterior circulation have been the most significant advance in acute ischemic stroke in the past 20 years. However, despite this marked advance, there are still many hurdles to improving access to thrombectomy worldwide. Additionally, despite these advances, a substantial portion of patients with LVO still are left disabled.

The major randomized trials focused on patients within 6 h from symptom onset, with occlusion of the ICA or proximal MCA, small amount of permanently damaged brain, and a moderate to large clinical deficit. We will explore the role of thrombectomy outside of these areas, but also explore larger issues as they pertain to re-organization of stroke systems of care to improve access to this remarkable therapy. Now that we have proven, without a shadow of doubt, that rapid revascularization with mechanical thrombectomy improves outcomes in LVO stroke, we must reorganize our systems of care to improve access and assess the role for MT outside of the patients who meet trial criteria.