Tools
Anesthesia for Endovascular Therapy for Acute Ischemic Stroke in Adults
Introduction
Approximately 795,000 people suffer from stroke annually in the US. According to this estimate, 1 person gets a stroke every 40 seconds, and approximately 1 patient dies due to a stroke every 4 minutes.[1] Acute stroke can be classified as ischemic, hemorrhagic, subarachnoid, cerebral thrombosis, and spinal stroke.[2] About 80 to 87% of all strokes are of ischemic origin. Ischemic stroke is further divided into 5 subtypes:[3][4][5]
- Large-artery atherosclerosis
- Cardioembolism
- Small-vessel occlusion
- Stroke of other determined etiology
- Stroke of undetermined etiology
Risk factors of stroke can be divided into modifiable and non-modifiable. Modifiable factors are hypertension, diabetes, hyperlipidemia, tobacco use, alcohol and drug use, physical inactivity, and atrial fibrillation. Non-modifiable factors are age, sex, race, and genetics.
Anatomy and Physiology
Register For Free And Read The Full Article
Search engine and full access to all medical articles- 10 free questions in your specialty
- Free CME/CE Activities
- Free daily question in your email
- Save favorite articles to your dashboard
- Emails offering discounts
Learn more about a Subscription to StatPearls Point-of-Care
Anatomy and Physiology
Cerebral Circulation: Arterial System and Venous System
The arterial blood flow to the brain is through 2 primary sources: the anterior source is provided by internal carotid arteries, and the posterior source originates in vertebral arteries. Internal carotid and vertebral arteries confluence at the circle of Willis, and from there, all the major cerebral arteries arise. Thus, the arteries supplying brain tissue are the anterior cerebral artery, middle cerebral artery, anterior choroidal artery, posterior cerebral artery, anterior inferior cerebellar artery, posterior inferior cerebellar artery, and basilar artery.
Cerebral venous system: superficial dural venous sinuses and deep cerebral veins.[6]
Acute Ischemic stroke (AIS) is caused by deficient blood and oxygen supply to the brain; hemorrhagic stroke is caused by bleeding or leaky blood vessels.
Pathophysiology
In ischemic stroke, acute occlusion of blood vessels is most commonly embolic, while rupture of atherosclerotic plaque is a less common cause.[7] This leads to a reduction in blood flow and cell death. Approximately 10 to 15% of all strokes are hemorrhagic (caused by ruptured blood vessels) and are associated with high mortality. After an acute stroke, the ischemic brain tissue (core) area is surrounded by reversibly damaged tissue called the penumbra.[8] This tissue is salvageable and is the focus of stroke treatment.[9]
Indications
Indications of endovascular therapy in acute ischemic stroke are patients who present late. They are out of the window for intravenous recombinant-type tissue plasminogen activator (IV rtPA) therapy, those who have contraindications to IV rtPA therapy (eg, recent surgery or coagulopathy), or who have failed IV rtPA therapy.[10] Outcomes are favorable in patients who receive thrombectomy and standard medical care within 6 to 24 hours of the onset of symptoms.[11]
Equipment
The equipment used for brain imaging, non-contrast computed tomography (NCCT), and diffusion weight magnetic resonance imaging (DW-MRI) includes:
Cerebral Angiography
- Airway equipment, endotracheal tubes, laryngoscopes, glide scopes
- Anesthesia machine
- Oxygen
- Anesthesia induction agents, propofol, etomidate, people with paralysis
- Vasoactive medications such as vasopressors and anti-hypertensive drugs
- Ultrasound machine for rapid vascular access/arterial line cannulation
- Arterial blood gas analyzer
- Glucometers
For Mechanical Thrombectomy
- Stent retriever
- Mechanical embolus removal in cerebral ischemia (MERCI) device
- The proximal balloon guide catheter
- A large-bore distal access catheter
- Cervical guide catheter
Standard American Society of Anesthesiology (ASA) monitors include pulse oximeters, electrocardiograms, noninvasive and invasive blood pressure monitoring, temperature monitoring, and end-tidal carbon dioxide monitors.
Personnel
An interprofessional care team includes emergency department personnel, neurointerventionalists, anesthesiologists, neurologists, neurosurgeons, neurocritical care specialists, nurses, and technicians.
Preparation
Mechanical thrombectomy is an emergent procedure. Therefore, the neuro-angiography suite/operating room (OR) should be prepared well in advance for endovascular treatment of stroke to avoid any delay in anesthesia. An anesthesia machine should be checked and ready to go. Airway equipment, monitoring devices, venous access kits, and drugs should also be ready for starting and maintaining anesthesia.
Technique or Treatment
Hemorrhagic Stroke
Treatment modalities for hemorrhagic stroke mainly revolve around hypertension control and surgical evacuation of the hematoma.[12][13] The benefits of either of these interventions in improving the outcome of hemorrhagic stroke are uncertain. Studies comparing the effect of target systolic blood pressure of 110 to 139 mmHg vs. 140 to 179 mmHg did not show a reduction in mortality and morbidity in patients suffering from hemorrhagic stroke.[14] Early surgery for hematoma evacuation has some survival benefits.[15]
Acute Ischemic Stroke (AIS)
Brain tissue is lost rapidly after stroke, so the time-is-brain concept was introduced to emphasize the need for emergent evaluation and treatment to limit its progress.[16] Quantitative neurostereology and stroke neuroimaging show that for every minute of untreated large vessel stroke, the brain loses approximately 1.9 million neurons. Therefore, 1 of the significant anesthetic concerns is preserving the penumbra region. It lasts only a few hours for humans.[17] Every attempt should be made to avoid the delay of anesthesia.
There is an ongoing debate about the effectiveness of general anesthesia (GA) over conscious sedation and vice versa, as some studies have shown that GA is associated with a lower disability. In contrast, others demonstrated worse outcomes with GA.[18][19][20][21]
Anastasian enumerated the advantages and disadvantages of GA and local anesthesia.[10] The advantages of GA are immobility, pain control, and airway protection, while the disadvantages are more hemodynamic changes and time delay at the start of the procedure. The advantages of local anesthesia are superior hemodynamics and neurological evaluation, while the disadvantages are patient movement, pain, agitation, and loss of airway control.
American Heart Association/ American Stroke Association (AHA/ASA) guidelines recommend that the choice of anesthetic technique should be based on patient risk factors, clinical conditions, and technical performance of the procedure. They recommend that either method, GA or procedural sedation, is reasonable until more data is available. Society for neuroscience in anesthesiology and critical care (SNACC) expert consensus statement also recommends that anesthesia be tailored according to the patient’s clinical condition.[22][23]
Blood pressure, heart rate, electrocardiogram, oxygen saturation, and end-tidal carbon dioxide concentration should be monitored throughout the procedure. Invasive arterial blood pressure should be employed to monitor beat-to-beat pressure.[23] Hypertension is present in about 80% of patients presenting with acute ischemic stroke.[24]
A U-shaped relationship exists between blood pressure and neurological outcome, with hypertension and hypotension both associated with poor outcomes. Data shows that the best neurological outcomes are observed at a systolic blood pressure of 150 mmHg (range between 140 to 179 mmHg).[25] Diastolic blood pressure should be maintained at < 105 mmHg.[23] AHA/ASA guidelines recommend maintaining BP ≤180/105 mmHg during and for 24 hours after mechanical thrombectomy.
For patients presenting with hypertension in the setting of AIS, the overall clinical picture should be taken into account, for example, patients with acute coronary syndrome, acute heart failure, aortic dissection, or post-thrombolysis symptomatic intracerebral hemorrhage. In these cases, the initial lowering of BP should not be more than 15% of the baseline.[22] Different antihypertensive options to control BP as recommended by AHA/ASA are:
- Labetalol 10 to 20 mg IV over 1 to 2 min, may repeat 1 time; or
- Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5 to 15 min, maximum 15 mg/h;
- Clevidipine 1 to 2 mg/h IV, titrate by doubling the dose every 2 to 5 min until desired BP reached; maximum 21 mg/h
- Other agents (eg, hydralazine and enalaprilat) may also be considered.
If BP is not controlled or diastolic BP >140 mm Hg, IV sodium nitroprusside can be considered. Anesthesia should be planned in a way that avoids hypotension and acute fluctuations in blood pressure, as they are associated with loss of penumbra.[26]
Hypotension is associated with poor outcomes in the setting of acute ischemic stroke.[10] Systolic blood pressure <140 mmHg is an independent predictor of poor neurologic outcome. Hypotension and hypovolemia should be corrected to achieve hemodynamic stability and organ perfusion. Excessive volume expansion is not recommended, as it may lead to hemodilution. If hypoglycemia is not a concern, non-glucose-containing fluids should be used.
Aspirin should be administered in patients with AIS within 24 to 48 hours after onset, but it should not be used as a substitute for treatment with thrombolysis or mechanical thrombectomy. Supplemental oxygen should be used to maintain oxygen saturation >94% or PaO2 > 60 mmHg.[27] All the measures should be taken to avoid hypoxia, hypercapnia, and hypocapnia.
Body temperature should be maintained between 35 and 37 degrees centigrade. Causes of hyperthermia (temperature >38 degrees C) should be identified and treated. Antipyretic medications and cooling devices should be used to correct the temperature when needed.
Blood sugar should be closely monitored, and hypoglycemia (blood glucose <60 mg/dL) and hyperglycemia should be avoided. AHA/ASA recommends target blood sugar levels of 140 to 180 mg/dl.[22] SNACC consensus statement recommends maintaining blood sugar levels between 70 and 140 mg/dl.[23]
Routine use of prophylactic antibiotics, antiseizure drugs, and flathead positioning has not been proven beneficial. After the procedure, the patient should be transferred to the neuro-critical care unit for continued hemodynamic and neurological monitoring.
Complications
Potential complications are intracranial hemorrhage, vessel dissection, emboli to new vascular territories, vasospasm, stent dislocation/occlusion, and extravasation.[28][29]
Clinical Significance
It cannot be emphasized enough that delays in anesthesia and, hence, treatment of acute ischemic stroke must be avoided. More delay causes more loss of penumbra and, hence, worse outcomes. The provision of hemodynamic stability is 1 of the most important anesthetic goals for patients undergoing mechanical thrombectomy for acute ischemic stroke.
Enhancing Healthcare Team Outcomes
Management of a patient with acute ischemic stroke requires a multidisciplinary effort, with multiple teams working at different levels and in coordination with each other. This requires efficient communication between teams. Code stroke should be initiated so all teams can deliver their responsibilities. For example, when the patient arrives in the ED, physicians (ED physician, neurologist, anesthesiologist) should quickly assess the patient, stabilize them, and send them for a CT scan.
Meanwhile, nursing staff and technicians should be ready for the scan. If it is determined that the patient has an acute ischemic stroke, has no contraindications, and is within the time frame of intravenous recombinant tissue plasminogen activator treatment, it should be administered. If not, he should be taken to the OR, avoiding any delay for mechanical thrombectomy.
The anesthesiologist should decide if he requires general anesthesia or conscious sedation, depending on the clinical situation. Intraoperatively, care should be provided according to standard management protocols (AHA/ASA guidelines, SNACC recommendations), maintaining hemodynamic and metabolic parameters, and providing adequate oxygenation and ventilation, all with an intent to salvage penumbra and limit neurological disability.
Nursing, Allied Health, and Interprofessional Team Interventions
Whenever a patient with suspected acute stroke symptoms presents, code stroke is called, and many different teams come into play. They work together and in succession to give the best care possible. With so many different persons working together, efficient communication becomes important.
Different teams may decide on interventions at different times during the hospital stay. An ED physician/anesthesiologist may decide to intubate the patient if he thinks the patient’s consciousness is declining, a neurologist may decide on starting thrombolysis/thrombectomy, and an interventional radiologist may help with mechanical thrombectomy. Also, different teams may get involved in treating stroke complications or their treatment. Good communication is valuable in all these scenarios.
Nursing, Allied Health, and Interprofessional Team Monitoring
Given the complexity of the procedure and co-morbidities associated with the patient, the importance of vigilant monitoring cannot be emphasized more. Neurologic parameters (consciousness, mental status), hemodynamic parameters (hypo/hypertension, cardiac rhythms, heart rate), metabolic parameters (blood sugar, renal function), and other clinical factors such as temperature should be continuously monitored. Effective communication should be established between the interprofessional team, and adequate interventions should be carried out in the best interest of the patients.
References
Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, de Ferranti SD, Floyd J, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Mackey RH, Matsushita K, Mozaffarian D, Mussolino ME, Nasir K, Neumar RW, Palaniappan L, Pandey DK, Thiagarajan RR, Reeves MJ, Ritchey M, Rodriguez CJ, Roth GA, Rosamond WD, Sasson C, Towfighi A, Tsao CW, Turner MB, Virani SS, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P, American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association. Circulation. 2017 Mar 7:135(10):e146-e603. doi: 10.1161/CIR.0000000000000485. Epub 2017 Jan 25 [PubMed PMID: 28122885]
Amarenco P, Bogousslavsky J, Caplan LR, Donnan GA, Hennerici MG. Classification of stroke subtypes. Cerebrovascular diseases (Basel, Switzerland). 2009:27(5):493-501. doi: 10.1159/000210432. Epub 2009 Apr 3 [PubMed PMID: 19342825]
Dietl M, Pohle R, Weingärtner M, Polgar R, Grässel E, Schwab S, Kolominsky-Rabas P. [Stroke etiology and long-term need of care in ischemic stroke patients]. Fortschritte der Neurologie-Psychiatrie. 2009 Dec:77(12):714-9. doi: 10.1055/s-0028-1109912. Epub 2009 Nov 30 [PubMed PMID: 19950047]
Kuriakose D,Xiao Z, Pathophysiology and Treatment of Stroke: Present Status and Future Perspectives. International journal of molecular sciences. 2020 Oct 15; [PubMed PMID: 33076218]
Level 3 (low-level) evidenceAdams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993 Jan:24(1):35-41 [PubMed PMID: 7678184]
Level 1 (high-level) evidenceChandra A, Li WA, Stone CR, Geng X, Ding Y. The cerebral circulation and cerebrovascular disease I: Anatomy. Brain circulation. 2017 Apr-Jun:3(2):45-56. doi: 10.4103/bc.bc_10_17. Epub 2017 Jul 18 [PubMed PMID: 30276305]
Musuka TD, Wilton SB, Traboulsi M, Hill MD. Diagnosis and management of acute ischemic stroke: speed is critical. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2015 Sep 8:187(12):887-93. doi: 10.1503/cmaj.140355. Epub 2015 Aug 4 [PubMed PMID: 26243819]
Liu S, Levine SR, Winn HR. Targeting ischemic penumbra: part I - from pathophysiology to therapeutic strategy. Journal of experimental stroke & translational medicine. 2010 Mar 15:3(1):47-55 [PubMed PMID: 20607107]
Ramos-Cabrer P, Campos F, Sobrino T, Castillo J. Targeting the ischemic penumbra. Stroke. 2011 Jan:42(1 Suppl):S7-11. doi: 10.1161/STROKEAHA.110.596684. Epub 2010 Dec 16 [PubMed PMID: 21164112]
Anastasian ZH. Anaesthetic management of the patient with acute ischaemic stroke. British journal of anaesthesia. 2014 Dec:113 Suppl 2():ii9-16. doi: 10.1093/bja/aeu372. Epub [PubMed PMID: 25498583]
Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, Yavagal DR, Ribo M, Cognard C, Hanel RA, Sila CA, Hassan AE, Millan M, Levy EI, Mitchell P, Chen M, English JD, Shah QA, Silver FL, Pereira VM, Mehta BP, Baxter BW, Abraham MG, Cardona P, Veznedaroglu E, Hellinger FR, Feng L, Kirmani JF, Lopes DK, Jankowitz BT, Frankel MR, Costalat V, Vora NA, Yoo AJ, Malik AM, Furlan AJ, Rubiera M, Aghaebrahim A, Olivot JM, Tekle WG, Shields R, Graves T, Lewis RJ, Smith WS, Liebeskind DS, Saver JL, Jovin TG, DAWN Trial Investigators. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. The New England journal of medicine. 2018 Jan 4:378(1):11-21. doi: 10.1056/NEJMoa1706442. Epub 2017 Nov 11 [PubMed PMID: 29129157]
Qureshi AI, Qureshi MH. Acute hypertensive response in patients with intracerebral hemorrhage pathophysiology and treatment. Journal of cerebral blood flow and metabolism : official journal of the International Society of Cerebral Blood Flow and Metabolism. 2018 Sep:38(9):1551-1563. doi: 10.1177/0271678X17725431. Epub 2017 Aug 16 [PubMed PMID: 28812942]
Wilkinson DA, Keep RF, Hua Y, Xi G. Hematoma clearance as a therapeutic target in intracerebral hemorrhage: From macro to micro. Journal of cerebral blood flow and metabolism : official journal of the International Society of Cerebral Blood Flow and Metabolism. 2018 Apr:38(4):741-745. doi: 10.1177/0271678X17753590. Epub 2018 Jan 19 [PubMed PMID: 29350086]
Qureshi AI, Palesch YY, Barsan WG, Hanley DF, Hsu CY, Martin RL, Moy CS, Silbergleit R, Steiner T, Suarez JI, Toyoda K, Wang Y, Yamamoto H, Yoon BW, ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. The New England journal of medicine. 2016 Sep 15:375(11):1033-43. doi: 10.1056/NEJMoa1603460. Epub 2016 Jun 8 [PubMed PMID: 27276234]
Mendelow AD, Gregson BA, Rowan EN, Murray GD, Gholkar A, Mitchell PM, STICH II Investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet (London, England). 2013 Aug 3:382(9890):397-408. doi: 10.1016/S0140-6736(13)60986-1. Epub 2013 May 29 [PubMed PMID: 23726393]
Level 1 (high-level) evidenceSaver JL. Time is brain--quantified. Stroke. 2006 Jan:37(1):263-6 [PubMed PMID: 16339467]
Saver JL. The 2012 Feinberg Lecture: treatment swift and treatment sure. Stroke. 2013 Jan:44(1):270-7. doi: 10.1161/STROKEAHA.112.671354. Epub 2012 Dec 13 [PubMed PMID: 23238857]
Schönenberger S,Hendén PL,Simonsen CZ,Uhlmann L,Klose C,Pfaff JAR,Yoo AJ,Sørensen LH,Ringleb PA,Wick W,Kieser M,Möhlenbruch MA,Rasmussen M,Rentzos A,Bösel J, Association of General Anesthesia vs Procedural Sedation With Functional Outcome Among Patients With Acute Ischemic Stroke Undergoing Thrombectomy: A Systematic Review and Meta-analysis. JAMA. 2019 Oct 1; [PubMed PMID: 31573636]
Level 1 (high-level) evidenceZhang Y, Jia L, Fang F, Ma L, Cai B, Faramand A. General Anesthesia Versus Conscious Sedation for Intracranial Mechanical Thrombectomy: A Systematic Review and Meta-analysis of Randomized Clinical Trials. Journal of the American Heart Association. 2019 Jun 18:8(12):e011754. doi: 10.1161/JAHA.118.011754. Epub 2019 Jun 11 [PubMed PMID: 31181981]
Level 1 (high-level) evidenceCappellari M, Pracucci G, Forlivesi S, Saia V, Nappini S, Nencini P, Inzitari D, Greco L, Sallustio F, Vallone S, Bigliardi G, Zini A, Pitrone A, Grillo F, Musolino R, Bracco S, Tinturini R, Tassi R, Bergui M, Cerrato P, Saletti A, De Vito A, Casetta I, Gasparotti R, Magoni M, Castellan L, Malfatto L, Menozzi R, Scoditti U, Causin F, Baracchini C, Puglielli E, Casalena A, Ruggiero M, Malatesta E, Comelli C, Chianale G, Lauretti DL, Mancuso M, Lafe E, Cavallini A, Cavasin N, Critelli A, Ciceri EFM, Bonetti B, Chiumarulo L, Petruzzelli M, Giorgianni A, Versino M, Ganimede MP, Tinelli A, Auteri W, Petrone A, Guidetti G, Nicolini E, Allegretti L, Tassinari T, Filauri P, Sacco S, Pavia M, Invernizzi P, Nuzzi NP, Carmela Spinelli M, Amistà P, Russo M, Ferrandi D, Corraine S, Craparo G, Mannino M, Simonetti L, Toni D, Mangiafico S. General Anesthesia Versus Conscious Sedation and Local Anesthesia During Thrombectomy for Acute Ischemic Stroke. Stroke. 2020 Jul:51(7):2036-2044. doi: 10.1161/STROKEAHA.120.028963. Epub 2020 Jun 10 [PubMed PMID: 32517584]
Level 3 (low-level) evidenceDavis MJ, Menon BK, Baghirzada LB, Campos-Herrera CR, Goyal M, Hill MD, Archer DP, Calgary Stroke Program. Anesthetic management and outcome in patients during endovascular therapy for acute stroke. Anesthesiology. 2012 Feb:116(2):396-405. doi: 10.1097/ALN.0b013e318242a5d2. Epub [PubMed PMID: 22222475]
Level 2 (mid-level) evidencePowers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec:50(12):e344-e418. doi: 10.1161/STR.0000000000000211. Epub 2019 Oct 30 [PubMed PMID: 31662037]
Talke PO, Sharma D, Heyer EJ, Bergese SD, Blackham KA, Stevens RD. Republished: Society for Neuroscience in Anesthesiology and Critical Care expert consensus statement: Anesthetic management of endovascular treatment for acute ischemic stroke. Stroke. 2014 Aug:45(8):e138-50. doi: 10.1161/STROKEAHA.113.003412. Epub [PubMed PMID: 25070964]
Level 3 (low-level) evidenceSare GM, Geeganage C, Bath PM. High blood pressure in acute ischaemic stroke--broadening therapeutic horizons. Cerebrovascular diseases (Basel, Switzerland). 2009:27 Suppl 1():156-61. doi: 10.1159/000200454. Epub 2009 Apr 3 [PubMed PMID: 19342846]
Leonardi-Bee J, Bath PM, Phillips SJ, Sandercock PA, IST Collaborative Group. Blood pressure and clinical outcomes in the International Stroke Trial. Stroke. 2002 May:33(5):1315-20 [PubMed PMID: 11988609]
Level 2 (mid-level) evidenceJeong HG,Kim BJ,Kim H,Jung C,Han MK,Liebeskind DS,Bae HJ, Blood Pressure Drop and Penumbral Tissue Loss in Nonrecanalized Emergent Large Vessel Occlusion. Stroke. 2019 Oct; [PubMed PMID: 31462194]
Tinoco CSL, Santos PMCD. [Anesthetic management of endovascular treatment for acute ischemic stroke: Influences on outcome and complications]. Brazilian journal of anesthesiology (Elsevier). 2018 Nov-Dec:68(6):613-623. doi: 10.1016/j.bjan.2018.06.004. Epub 2018 Sep 6 [PubMed PMID: 30195628]
Behme D, Gondecki L, Fiethen S, Kowoll A, Mpotsaris A, Weber W. Complications of mechanical thrombectomy for acute ischemic stroke-a retrospective single-center study of 176 consecutive cases. Neuroradiology. 2014 Jun:56(6):467-76. doi: 10.1007/s00234-014-1352-0. Epub 2014 Mar 26 [PubMed PMID: 24668181]
Level 2 (mid-level) evidenceKurre W, Pérez MA, Horvath D, Schmid E, Bäzner H, Henkes H. Does mechanical thrombectomy in acute embolic stroke have long-term side effects on intracranial vessels? An angiographic follow-up study. Cardiovascular and interventional radiology. 2013 Jun:36(3):629-36. doi: 10.1007/s00270-012-0496-8. Epub 2012 Oct 20 [PubMed PMID: 23086452]
Level 2 (mid-level) evidence