Issue 01/April 2024

Road to Recovery in Stroke: Mechanical Thrombectomy

By: Dr. Hiren Patel

Stroke is a major global public health problem, being the second leading cause of death worldwide. Asians have a higher prevalence of stroke than coronary heart disease, and there is no difference in stroke occurrence between males and females in India.

A stroke occurs when blood supply to the brain is blocked. More than 80% of all strokes result from blockage of the artery, called Ischemic stroke, whereas hemorrhagic strokes are caused by bleeding, which accounts for less than 20%.

The symptoms and signs of acute stroke according to the area involved are: loss of balance (B), blurring of vision (E), deviation of mouth (F), limb weakness (A), and speech difficulty (S). It's time to call (T) a stroke-ready hospital (BEFAST). We have to identify these signs as early as possible because "Time is Brain". Every minute, 1.9 million neurons are dying.

Major risk factors for stroke include hypertension, diabetes mellitus, smoking, high homocysteine/low Vitamin B12, hyperlipidemia, obesity, and stress.

Two important time-sensitive treatments available for treating stroke are Intravenous Thrombolysis and Mechanical Thrombectomy (MT). Intravenous thrombolysis can be administered only if the patient reaches the hospital within 4.5 hours from noticing the initial symptoms. MT is performed on patients with stroke who have a blockage in one of the major arteries inside the brain, leading to severe stroke.

Severe stroke and the need for Mechanical Thrombectomy: About half of the patients with acute stroke have large vessel occlusion and present with severe stroke. These are candidates for MT as IVT cannot dissolve a large quantity of clot. Without timely treatment, these patients may end up with severe disabilities or even death.

Patient selection for MT: Patients who present with acute ischemic stroke should undergo MRI/CT stroke protocol to assess the ischemic area and major vessel occlusion. Patients are considered for MT if their clinical presentation is within 24 hours of the onset of symptoms and ASPECTS is favorable (≥ 4), with a large vessel occlusion demonstrated on CTA or MRA. It is important to check clinical-imaging mismatch.

Bridging Treatment: IVT followed by MT is the current standard of practice in most Stroke Ready Hospitals when patients arrive within 4.5 hours.

The MT procedure involves Neurointerventionalists who use Stent retrievers/Aspiration catheters to remove the clot from the blocked brain vessel. If timely treatment is given, MT can restore blood flow in the blocked vessel in 80-90% of cases with good clinical recovery and significantly reduce disabilities and death in 40-60% of cases, thereby reducing the overall stroke burden on society.

Illustrative case: A young male (30 years old) with right-sided weakness and global aphasia for 1 hour underwent successful bridging treatment: IVT and MT. The patient improved neurologically and became independent.

Timely treatment at a "Stroke Ready Hospital" by the "Stroke Team" will reduce the global stroke burden, disabilities, and death. Public awareness about acute stroke, its signs/symptoms, and early recognition by nearby stroke-ready hospitals can save many lives.

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