When should intra arterial therapy be used for acute ischemic stroke?
The role for IA therapy is rapidly evolving. After three randomized controlled trials (RCTs) of older IA devices failed to show improved clinical outcomes, four RCTs primarily using stent retriever devices all demonstrated improved clinical outcomes, although it is not clear that the device is the sole explanation for the better outcomes.
Most but not all patients in these recent trials received IV tPA. Each trial used different selection criteria, mostly enrolling patients without evidence of a completed stroke on imaging and residual perfusion by vascular imaging.
These trials are being carefully assessed, and recommendations for the appropriate use of IA are pending.
Until then, IA therapy with stent retriever devices is reasonable in patients with device-accessible proximal large vessel occlusions without early ischemic changes on brain imaging.
Given the dangers of reperfusion injury and device-related complications (11% to 16%), rapid therapy and careful patient selection are vital.
