Snare retrieval of intracranial thrombus in patients with acute stroke

Intravenous or intraarterial thrombolysis of intracranial emboli is becoming an accepted clinical treatment modality for acute ischemic stroke, but not all emboli respond to the lytic drug regimens available today. If drug therapy fails, mechanical retrieval seems warranted. Four patients whose condition was resistant to intravenous and intraarterial thrombolytic drug treatment underwent at least partial clot removal with use of a snare, and almost immediate clinical improvement was noted. A fifth patient's clot was removed before lytic drugs were administered. All five patients, who presented with a sudden onset of stroke, were evaluated by arterial angiography; then, after a failed trial of intraarterial fibrinolytic drugs, they were treated by passing a 2- or 4-mm snare through a microcatheter. The snare wire was guided around the thrombus, gently brought back toward the microcatheter - but not into it - and the entire microcatheter and snare assembly was then removed. In four of the five cases, follow-up angiography performed immediately after the retrieval showed wider distal branches than normal. Follow-up computed tomography results were abnormal in all cases, showing hyperdense material in the territory that was previously ischemic. This hyperdensity subsided within 48 hours in all but one patient who developed small parenchymal hemorrhages; however, he remained asymptomatic. The snare device offers an additional or alternative therapy until completely effective thrombolytic agents become available. Although use of a snare is not ideal, device improvements should make the retrieval less technically challenging and more effective. There is a need for improved mechanical extraction devices, especially in light of the patient improvement that occurred. This experience also suggests that immediate removal of a mature clot could reduce the total time of brain ischemia more quickly than administration of thrombolytic drugs.