Skip to main content Accessibility help
Hostname: page-component-6c8bd87754-x25dq Total loading time: 0.541 Render date: 2022-01-18T17:36:43.435Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "metricsAbstractViews": false, "figures": true, "newCiteModal": false, "newCitedByModal": true, "newEcommerce": true, "newUsageEvents": true }

Chapter 6 - Endovascular Therapy

Published online by Cambridge University Press:  28 October 2019

Mary Carter Denny
Georgetown University Hospital
Ahmad Riad Ramadan
Henry Ford Hospital, Detroit
Sean I. Savitz
University of Texas Health Science Center, Houston
James Grotta
Memorial Hermann Texas Medical School
Get access


When used alone, intravenous and intra-arterial thrombolysis have yielded low recanalization rates of proximal large-vessel occlusions (LVO). The endovascular trials utilizing first-generation devices such as the Merci retriever and the Penumbra aspiration system were essentially neutral and failed to demonstrate superiority of mechanical thrombectomy over IV tPA (MR RESCUE, SYNTHESIS, IMS-III). In 2015, however, six trials – MR CLEAN, EXTEND-IA, SWIFT PRIME, ESCAPE, REVASCAT, and THRACE – led to a fundamental shift in how we acutely manage LVOs today. All six trials compared endovascular thrombectomy (EVT) to IV tPA alone and demonstrated clear superiority of thrombectomy in patients presenting within 6 hours from the time they were last known well (LKW) if they met specific imaging criteria.

Acute Stroke Care , pp. 80 - 100
Publisher: Cambridge University Press
Print publication year: 2019

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


Kidwell, CS, Jahan, R, Gornbein, J, et al.; MR RESCUE Investigators. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 2013; 368: 914923.CrossRefGoogle ScholarPubMed
Ciccone, A, Valvassori, L, Nichelatti, M, et al.; SYNTHESIS Expansion Investigators. Endovascular treatment for acute ischemic stroke. N Engl J Med 2013; 368: 904913.CrossRefGoogle ScholarPubMed
Broderick, JP, Palesch, YY, Demchuk, AM, et al.; Interventional Management of Stroke (IMS) III Investigators. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 2013; 368: 893903.CrossRefGoogle ScholarPubMed
Berkhemer, OA, Fransen, PS, Beumer, D, et al.; MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372: 1120.CrossRefGoogle ScholarPubMed
Campbell, BC, Mitchell, PJ, Kleinig, TJ, et al.; EXTEND-IA Investigators. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015; 372: 10091018.CrossRefGoogle ScholarPubMed
Saver, JL, Goyal, M, Bonafe, A, et al.; SWIFT PRIME Investigators. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015; 372: 22852295.CrossRefGoogle ScholarPubMed
Goyal, M, Demchuk, AM, Menon, BK, et al.; ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015; 372: 10191030.CrossRefGoogle ScholarPubMed
Jovin, TG, Chamorro, A, Cobo, E, et al.; REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015; 372: 22962306.CrossRefGoogle ScholarPubMed
Bracard, S, Ducrocq, X, Mas, JL, et al.; THRACE investigators. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol 2016; 15: 11381147.CrossRefGoogle ScholarPubMed
Nogueira, RG, Jadhav, AP, Haussen, DC, et al.; DAWN Trial Investigators. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 2018; 378: 1121.CrossRefGoogle ScholarPubMed
Albers, GW, Marks, MP, Kemp, S, et al.; DEFUSE 3 Investigators. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 2018; 378: 708718.CrossRefGoogle ScholarPubMed
Mulder, MJHL, Jansen, IGH, Goldhoorn, RB, et al.; MR CLEAN Registry Investigators. Time to endovascular treatment and outcome in acute ischemic stroke: MR CLEAN registry results. Circulation 2018; 138: 232240.CrossRefGoogle ScholarPubMed
Meretoja, A, Keshtkaran, M, Tatlisumak, T, Donnan, GA, Churilov, L. Endovascular therapy for ischemic stroke: save a minute–save a week. Neurology 2017; 88: 21232127.CrossRefGoogle Scholar
Powers, WJ, Rabinstein, AA, Ackerson, T, et al.; American Heart Association Stroke Council. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2018; 49: e46e110.CrossRefGoogle ScholarPubMed
Sheinberg, DL, McCarthy, DJ, Peterson, EC, Starke, RM. DEFUSE-3 Trial: reinforcing evidence for extended endovascular intervention time window for ischemic stroke. World Neurosurg 2018; 112: 275276.CrossRefGoogle ScholarPubMed
Schönenberger, S, Uhlmann, L, Hacke, W, et al. Effect of conscious sedation vs general anesthesia on early neurological improvement among patients with ischemic stroke undergoing endovascular thrombectomy: a randomized clinical trial. JAMA 2016; 316: 19861996.CrossRefGoogle ScholarPubMed
Löwhagen Hendén, P, Rentzos, A, Karlsson, JE, et al. General anesthesia versus conscious sedation for endovascular treatment of acute ischemic stroke: the AnStroke trial (Anesthesia During Stroke). Stroke 2017; 48: 16011607.CrossRefGoogle Scholar
Simonsen, CZ, Sørensen, LH, Juul, N, et al. Anesthetic strategy during endovascular therapy: general anesthesia or conscious sedation? (GOLIATH – General or Local Anesthesia in Intra Arterial Therapy). A single-center randomized trial. Int J Stroke 2016; 11: 10451052.CrossRefGoogle ScholarPubMed
Zadat, O, Yoo, A, Khatri, P, et al. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke 2013; 44: 26502663.CrossRefGoogle Scholar
Hentschel, KA, Daou, B, Chalouhi, N, et al. Comparison of non-stent retriever and stent retriever mechanical thrombectomy devices for the endovascular treatment of acute ischemic stroke. J Neurosurg 2017; 126: 11231130.CrossRefGoogle ScholarPubMed
Whalin, MK, Halenda, KM, Haussen, DC, et al. Even small decreases in blood pressure during conscious sedation affect clinical outcome after stroke thrombectomy: an analysis of hemodynamic thresholds. AJNR Am J Neuroradiol 2017; 38: 294298.CrossRefGoogle ScholarPubMed
Goyal, M, Menon, BK, van Zwam, WH, et al.; HERMES collaborators. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387: 17231731.CrossRefGoogle ScholarPubMed
Singer, OC, Berkefeld, J, Nolte, CH, et al.; ENDOSTROKE Study Group. Mechanical recanalization in basilar artery occlusion: the ENDOSTROKE study. Ann Neurol 2015; 77: 415424.CrossRefGoogle ScholarPubMed
BASICS Study Group. The Basilar Artery International Cooperation Study (BASICS): study protocol for a randomised controlled trial. Trials 2013; 14: 200.CrossRef

Send book to Kindle

To send this book to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle.

Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats

Send book to Dropbox

To send content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about sending content to Dropbox.

Available formats

Send book to Google Drive

To send content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about sending content to Google Drive.

Available formats