The History of Endovascular Stroke Treatment: From Local Intraarterial Fibrinolysis to Stent Retriever Thrombectomy

Abstract

Background

Acute thromboembolic occlusions of large intracranial arteries are associated with high rates of permanent disability and mortality. Intravenous thrombolysis (IVT) in these patients resulted in an inadequate rate of recanalization and has had limited clinical success. Various endovascular procedures have been attempted to remove intracranial thrombi and reopen occluded vessels. These technical innovations led to the publication of initial case reports, but the methods ultimately did not endure. Endovascular treatment of acute cerebral ischemia was performed only rarely and in selected centers as part of individualized curative attempts. The Solitaire stent was originally developed to treat intracranial aneurysms through stent-assisted coil occlusion. The suggestion that this stent could also be used for intracranial thrombectomy was made as early as 2003 and was clinically confirmed in 2008. Releasing a Solitaire stent into an embolically occluded large cerebral artery, with an incubation time of approximately 3 minutes and slow retraction of the stent, has led to unprecedented success rates of thrombus removal and (sub)total recanalization in more than 90 % of patients.

Methods

This review article aimed to describe the steps in the development of endovascular stroke therapy, beginning with intra-arterial thrombolysis and early technical innovations leading to the eventual success of stent retriever thrombectomy.

Conclusion

The potential for mechanical recanalization of acutely occluded large cerebral arteries could not be fully exploited until the advent of stent retriever thrombectomy. The entire concept of stroke treatment fundamentally changed after complete and rapid recanalization first became possible. Randomized controlled trials have shown superiority of stent retriever thrombectomy over IVT. An unparalleled boom in endovascular stroke therapy followed.

Key Points

• The history of endovascular stroke treatment was marked by setbacks in the first three decades.

• Stent retriever thrombectomy is the first procedure enabling recanalization of acute large intracranial artery occlusions in more than 90 % of patients.

• Stent retriever thrombectomy has transformed stroke care and neuroradiology in unprecedented ways.

• Further technical improvements will enable even faster, safer, complete recanalization in the near future.

• Further improvements in clinical outcomes will probably be determined by aspects beyond endovascular methods alone.

Citation Format

• Buecke P, Cohen J, Klisch J et al. The History of Endovascular Stroke Treatment: From Local Intraarterial Fibrinolysis to Stent Retriever Thrombectomy. Fortschr Röntgenstr 2024; 196: 682 – 689

Zusammenfassung

Hintergrund

Akute thrombembolische Verschlüsse großer intrakranieller Arterien sind assoziiert mit einer hohen Rate an bleibender Behinderung und Mortalität. Die intravenöse Thrombolyse (IVT) führt bei diesen Patienten nur zu einer unzureichenden Rate an Rekanalisationen und ist von begrenztem klinischem Erfolg. Mit unterschiedlichen endovaskulären Verfahren wurde daher versucht, intrakranielle Thromben zu entfernen. Mehrere technische Neuerungen führten zwar zu ersten Fallbeschreibungen, hatten aber letztlich keinen Bestand. Die endovaskuläre Behandlung der akuten zerebralen Ischämie blieb eine in wenigen Zentren seltene und als individueller Heilversuch durchgeführte Prozedur. Der Solitaire Stent wurde ursprünglich entwickelt zur Behandlung intrakranieller Aneurysmen durch Stent-assistierte Coil-Okklusion. Die bereits 2003 geäußerte Vermutung, dass dieser Stent auch zur intrakraniellen Thrombektomie verwendet werden kann, wurde von uns 2008 klinisch bestätigt. Durch die Freisetzung eines Solitaire-Stents in einer embolisch verschlossenen großen Hirnarterie, einer Inkubationszeit von etwa 3 Minuten, und einem langsamen Rückzug des Stents, gelingt jetzt erstmalig die Thrombus-Entfernung und Rekanalisation in über 90 % der Patienten.

Methode

Der vorliegende Beitrag schildert die Entwicklungsschritte der endovaskulären Schlaganfallbehandlung von der intra-arteriellen Thrombolyse über frühe technische Innovationen bis hin zum Erfolg der Stent-basierten Thrombektomie.

Schlussfolgerung

Erst durch die Stent-basierte Thrombektomie konnte das Potenzial der mechanischen Rekanalisation akut verschlossener Hirnarterien in vollem Umfang ausgenutzt werden. Diese Beobachtung hat das gesamte Konzept der Schlaganfallbehandlung grundlegend verändert. Eine (häufig) komplette und rasche Rekanalisation wurde erstmalig möglich. Randomisierte kontrollierte Studien zeigten eine eindeutige Überlegenheit in Bezug auf Patientenunabhängigkeit und Mortalität gegenüber der IVT. Es folgte ein unvergleichlicher Boom in der endovaskulären Schlaganfalltherapie.

Kernaussagen

• Die Geschichte der endovaskulären Schlaganfallbehandlung war in den ersten Jahrzehnten von Rückschlägen geprägt.

• Die Stent Retriever-Thrombektomie ist das erste Verfahren überhaupt, das eine Rekanalisation großer intrakranieller Verschlüsse von Hirnarterien in über 90 % der Patienten ermöglicht.

• Die Stent Retriever-Thrombektomie hat die Schlaganfallversorgung und die Neuroradiologie in ungeahnter Weise verändert.

• Weitere technische Verbesserungen werden in naher Zukunft schnellere, sichere, vollständige Rekanalisationen ermöglichen.

• Über eine weitere Verbesserung des klinischen Ausgangs werden wahrscheinlich nicht nur endovaskuläre Methoden entscheiden.

Key words

ischemic stroke - large vessel occlusion - endovascular treatment - stent retriever - thrombectomy

Publication History

Received: 13 September 2023

Accepted: 02 November 2023

Article published online:
08 December 2023

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