The Neurosurgeon as a Stroke Specialist

Patient and procedure selection for mechanical thrombectomy: Toward personalized medicine and the role of artificial intelligence

Mechanical thrombectomy (MT) for ischemic stroke due to large vessel occlusion is standard of care. Evidence-based guidelines on eligibility for MT have been outlined and evidence to extend the treatment benefit to more patients, particularly those at the extreme ends of a stroke clinical severity spectrum, is currently awaited. As patient selection continues to be explored, there is growing focus on procedure selection including the tools and techniques of thrombectomy and associated outcomes. Artificial intelligence (AI) has been instrumental in the area of patient selection for MT with a role in diagnosis and delivery of acute stroke care. Machine learning algorithms have been developed to detect cerebral ischemia and early infarct core, presence of large vessel occlusion, and perfusion deficit in acute ischemic stroke. Several available deep learning AI applications provide ready visualization and interpretation of cervical and cerebral arteries. Further enhancement of AI techniques to potentially include automated vessel probe tools in suspected large vessel occlusions is proposed. Value of AI may be extended to assist in procedure selection including both the tools and technique of thrombectomy. Delivering personalized medicine is the wave of the future and tailoring the MT treatment to a stroke patient is in line with this trend.

Decompressive Hemicraniectomy in the Modern Era of Mechanical Thrombectomy

OBJECTIVES

We aim to determine the incidence of decompressive hemicraniectomy (DHC) in the modern era of mechanical thrombectomy techniques and improved revascularization outcomes.

METHODS

We performed a retrospective analysis of 512 patients admitted with acute ischemic strokes with anterior circulation large-vessel occlusion that were treated by mechanical thrombectomy from 2010-2019. The primary endpoint was the need for surgical decompression. Secondary endpoints were infarct size, hemorrhagic conversion, and functional outcome at hospital discharge.

RESULTS

Of the 512 patients, 18 (3.5%) underwent DHC at a median 2.0 days from stroke onset. The DHC group was significantly younger than the non-DHC group (P < 0.001), had worse reperfusion rates (P = 0.024) and larger infarct size (P < 0.001). Hemorrhagic conversion was more frequent in the DHC group but did not reach statistical significance (P = 0.08). From 2010-2015, 196 patients underwent a mechanical thrombectomy, 13 of whom (6.6%) required a DHC, while 316 patients underwent mechanical thrombectomy from 2016-2019 and only 5 patients required a DHC (1.6%; P = 0.002). Younger age (P < 0.001), urinary tract infection (P < 0.001) and increasing infarct size were significantly associated with needing a DHC. When controlling for other risk factors, higher thrombolysis in cerebral infarction score significantly reduced the need for decompressive hemicraniectomy (P = 0.004).

CONCLUSIONS

This is one of the largest single-center experiences demonstrating that improved recanalization decreased the need for DHC without increasing the risk of hemorrhagic conversion.