Mechanical Thrombectomy for Acute Ischemic Stroke

Endovascular mechanical clot removal in large-vessel-occlusion (LVO) ischemic stroke. The 2015 trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT) established thrombectomy as standard care for LVO stroke within 6 hours of onset. Later trials (DAWN, DEFUSE 3) extended the window to 24 hours in selected patients.

Time-critical procedure. "Time is brain" — every 15 minutes of door-to-reperfusion delay meaningfully reduces favorable outcome probability. Thrombectomy-capable centers operate 24/7 stroke call.

Workflow

Pre-hospital / ED triage — NIHSS stroke severity assessment, CT head (rule out hemorrhage), CTA (identify LVO), optional CT perfusion (identify salvageable penumbra).
Thrombolytic decision — IV tPA / tenecteplase if within window + no contraindication.
Cath lab mobilization — stroke team + anesthesia + interventional neuroradiologist / stroke neurologist.
Vascular access — typically femoral (sometimes radial).
Guide catheter + navigation to the occluded vessel — internal carotid artery or M1/M2 MCA branch.
Thrombectomy — stent retriever (Solitaire, Trevo) ± aspiration catheter. Multiple passes if initial recanalization fails.
Final angiography — TICI 2b/3 (successful reperfusion) is the goal.
Post-procedure — ICU admission, close neurologic monitoring.

Typical systems

Biplane neuro IR suite preferred — simultaneous orthogonal imaging reduces contrast dose + procedure time in the time-critical setting.

Clinical metrics

Door-to-groin time — goal under 60 min at comprehensive stroke centers
Door-to-reperfusion — goal under 90 min
TICI 2b/3 reperfusion rate — ≥80% is the current benchmark
90-day mRS 0-2 — functional independence; the ultimate outcome measure

Room considerations

24/7 availability is a system-level commitment. Comprehensive stroke centers staff neuro call around the clock.
Quick setup — pre-heparinized system, draped table, ready neuro trays.
Rapid imaging integration — CTA / CT perfusion results reviewable in the cath lab.

Dose considerations

Thrombectomy DAP can be high on complex cases with multiple passes. Modern dose-reduction (ClarityIQ on Azurion, CARE+ on Artis Q) is particularly valuable here.