Stead et al (2008) performed a systematic review and meta-analysis of mechanical thrombectomy in the treatment of ischemic stroke and assessed factors for technical and clinical success and survival. These researchers searched the literature using Medline and Embase for January 1, 2000 through March 1, 2006. Studies were limited to those in human beings; there were no language or study design restrictions. Validity assessment was performed using the Newcastle-Ottawa Scale. The pooled cohort was compared with a historical cohort matched for sex, age, and NIHSS. The search yielded 114 publications. Two authors determined inclusibility (inter-rater agreement, kappa = ). Mean pre-procedure NIHSS score was . The MCA (36 %) and the posterior circulation (38 %) were the most frequently occluded areas. The clot was accessible in 85 % of the patients. Hemorrhage occurred in 22 % of the patients. Of 81 patients with concurrent thrombolysis, % had hemorrhage compared with % of 66 patients without thrombolysis (p = ). Of the 126 patients with accessible clots, 36 % had a good mRS (less than or equal to 2) and 29 % died; in patients with inaccessible clots, 24 % had a good mRS and 38 % died. Factors associated with clinical success were younger age (p = ) and lower NIHSS score at admission to the hospital (p = ). Compared with a matched cohort, patients who received mechanical intervention were times more likely to have a good mRS (95 % CI: to ; p < ). The authors concluded that percutaneous mechanical embolectomy in the treatment of AIS is feasible and seems to provide an option for some patients seen after the interval for administration of IV tPA therapy has elapsed.
On the other hand, we feel that endovascular therapies may be potentially more beneficial as a treatment option. Encouraging results have been reported with intra-arterial administration of papaverine and angioplasty of accessible spastic vessels. Timing of endovascular treatment is critically important to be effective. Intervention should be performed soon after it is apparent that a patient is progressing or failing to improve despite maximal medical therapy and before the onset of cerebral infarction. Indeed, cerebral angiography with the possibility of angiopalsty has become a routine part of our protocol in the management of symptomatic vasospasm. Figure 1 shows an example of a patient with symptomatic basilar artery vasospasm who made a significant recovery (from obtundation to following commands) after angioplasty.