Endovascular thrombectomy

When stroke is due to occlusion of a large vessel (ie distal internal carotid artery, proximal middle cerebral artery [M1 segment], basilar artery—ususally detected by computed tomography angiography), endovascular thrombectomy is highly effective when performed within 6 hours of symptom onset. Eligible patients are usually a subset of those in whom intravenous alteplase is indicated, and both treatments can be given to the same patient. However, endovascular thrombectomy is appropriate when intravenous alteplase is contraindicated (eg the patient is taking an anticoagulant) or when patients present too late for alteplase therapy (between 4.5 and 6 hours after onset of stroke symptoms).

Endovascular thrombectomy may also be highly effective in patients who present 6 to 24 hours after onset of stroke symptoms, including those who wake up with symptoms. To be eligible, patients must have an occluded large vessel (as defined above) and salvageable brain tissue (as detected by computed tomography or magnetic resonance perfusion imaging).

Only a few specialised centres provide neurointerventional therapy, but most Australian states have (or are moving to) a system-wide, organised approach to providing this service—seek local expert advice.