World neurosurgery | 2019
Indications for Mechanical Thrombectomy Too Wide or Too Narrow?
Abstract
The indications for mechanical thrombectomy (MT) have expanded since the American Heart Association/American Stroke Association (AHA/ASA) published its first guideline on MT in 2013. Multiple subsequent randomized clinical trials of MT have proven its efficacy, including the DAWN and DEFUSE 3 trials. The current guideline from AHA/ASA provides Class I support for the use of MT for the following indications: 1. Internal carotid artery (ICA)/M1 Middle Cerebral Artery (MCA) occlusion, <6h, National Institutes of Health Stroke Scale (NIHSS) score ≥6, Alberta Stroke Program Early CT Score (ASPECTS) ≥6; 2. Large vessel occlusions (LVO) in the anterior circulation, between 6-16h, and meet DAWN or DEFUSE 3 eligibility criteria. There is also Class IIa evidence for the use of MT for LVO in the anterior circulation, 16-24h, that meet other DAWN eligibility criteria. In clinical practice, these Class I and IIa indications for MT are well followed; however, there are many other potential indications such as 1. M2 or M3 MCA occlusion, < 6 hours; 2. ASPECTS <6, ICA or M1 MCA occlusion, <6 hours; 3. NIHSS score <6, ICA or M1 occlusion , <6 hours; 4. Tandem occlusions; 5. Posterior circulation occlusion < 6 hr. This review analyses the available data to provide support for further prospective clinical trials in regard to these potential indications.