Evaluating patients for thrombectomy

The treatment of acute ischemic stroke patients with a proximal large vessel occlusion (LVO) in the anterior circulation has seen tremendous advances initially with the demonstration of the substantial benefit of thrombectomy within 6-h of stroke onset and then with the demonstration of thrombectomy in carefully selected patients up to 24-h from onset. In both the early and late time windows, imaging played an important role in patient selection, especially in the later time window trials where very strict imaging inclusion criteria were employed to identify patients with a small/moderate sized ischemic core on computed tomography perfusion scanning and diffusion-weighted magnetic resonance imaging. In clinical practice, it is important to identify LVO patients quickly so several scoring scales have been developed to help route appropriate patients to a thrombectomy capable center. The recently reported thrombectomy trials left many unanswered questions such as do patients with more distal vessel occlusions benefit, do patients with LVO and mild clinical deficits benefit from thrombectomy, what is the largest extent of baseline ischemic core that still benefits from thrombectomy and what is the best approach to anesthesia with thrombectomy. These questions and other are being addressed in ongoing and future clinical trials that will likely expand the indications and safety for this powerfully effective therapy and also determine if neuroprotection is synergistic with thrombectomy.