脳塞栓〈適応と成績編〉

Evidence and Patient Selection for Endovascular Reperfusion Therapy for Acute Ischemic Stroke:A Narrative Review

Point

・経動脈的血栓溶解療法や主にMerciリトリーバー^®（Concentric Medical）を用いた血管内再開通療法は，内科治療に優る転帰改善効果を示すことができなかった．

・主にステントリトリーバーを用いたMR CLEAN以降の試験結果より，NIHSS ≧ 6の内頚動脈/中大脳動脈M1部閉塞で，ASPECTS ≧ 6の症例に対する発症6時間以内の血栓回収療法は標準治療となった．

・DAWN，DEFUSE 3の結果から，発症6時間以降の神経症状と虚血コアにミスマッチのある前方循環主幹動脈閉塞例に対する血栓回収療法の有効性も確立した．

・ASPECTS 3〜5の広範梗塞例や，PC-ASPECTS ≧ 6の脳底動脈閉塞例に対する血栓回収療法の有意な転帰改善効果が報告されている．

　Three former stroke trials failed to show the efficacy of endovascular stroke reperfusion therapy using intra-arterial thrombolysis or older-generation mechanical thrombectomy devices, compared with usual medical care in 2013. However, five pivotal trials in 2015（MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, and REVASCAT）, using newer-generation devices（e.g., stent retrievers）, have shown stroke thrombectomy to clearly improve the functional outcome of patients with occlusion of the internal carotid artery or the M1 portion of the middle cerebral artery（baseline National Institutes of Health Stroke Scale score ≥ 6; baseline Alberta Stroke Program Early Computed Tomography Score ≥ 6）, and who could receive thrombectomy within 6 h of symptom onset . In 2018, the efficacy of stroke thrombectomy for late-presenting patients with up to 16-24 h of onset and those who had a mismatch between neurological severity and ischemic core volume was also established by the DAWN and DEFUSE 3 trials. In 2022, the efficacies of stroke thrombectomy for patients with a large ischemic core or basilar artery occlusion were identified. This article discusses the evidence and patient selection for endovascular reperfusion therapy for acute ischemic stroke.