Perspective:

The following are 10 points to remember about this state-of-the-art paper on acute stroke intervention:

1. Approximately 795,000 new or recurrent strokes occur annually in the United States, resulting in direct costs of over 73 billion dollars.

2. Recent advances in mechanical thrombectomy for treatment of stroke have shown great promise in stroke care. Together with intravenous (IV) administration of tissue plasminogen activator (t-PA), endovascular interventions assist in the acute management of patients with large-vessel occlusions.

3. IV thrombolytic therapy remains the standard of care for patients who meet selection criteria. These criteria include onset of stroke <4.5 hours (~8 hours for mechanical revascularization); however, patients with longer duration from onset of symptoms can be considered for therapy depending on factors observed with perfusion imaging. In general, optimal reperfusion is observed in the first 60 minutes after therapy, after which recanalization rates drop significantly.

4. Studies of intra-arterial thrombolysis have also shown promise. Recanalization success relates to thromboembolic carotid territory occlusions, which correspond to thromboembolus location but not stroke etiology.

5. Current data suggest the combination of IV t-PA with intra-arterial lysis has potential for added benefit beyond what is observed with IV therapy, although this is not currently a class 1 recommendation.

6. Patient-related factors that are key for selection of endovascular therapy include time from onset of symptoms, severity of neurological deficit defined by the National Institutes of Health Stroke Scale (>8), age (under 80 years of age), baseline functional status, and vascular anatomy. For patients who present within 4.5 hours of symptom onset, the possibility of t-PA as a therapy alone or as a bridge to endovascular intervention should be considered for treatment.

7. A key component of initial evaluation includes a computed tomography (CT) scan. The authors recommend a stroke protocol that includes noncontrast CT to exclude hemorrhage and structural abnormalities, CT perfusion to determine abnormalities in cerebral blood flow, and CT angiography of the intracranial blood vessels and aortic arch.

8. Mechanical revascularization can be successfully accomplished in patients who have received IV t-PA.

9. Stent-assisted revascularization for acute ischemic stroke is currently being evaluated and may offer benefit in selected patients. There is a significant potential risk related to stent failure and hemorrhage related to such therapy.

10. Technical advances in mechanical thrombectomy and perfusion imaging will continue to expand the number of patients who benefit from these therapies for the treatment of ischemic stroke.