Acute Ischemic Stroke Intervention

Khandelwal P, Yavagal DR, Sacco RL.
Acute Ischemic Stroke Intervention. J Am Coll Cardiol 2016;67:2631-2644.

The following are key points to remember from this review about acute ischemic stroke (AIS) intervention:

  1. AIS is the leading cause of disability worldwide and a major cause of mortality.
  2. Although intravenous tissue plasminogen activator (IV-rtPA) was approved nearly two decades ago for treatment of AIS, only a minority of patients receive it due to a narrow time window for administration and several contraindications to its use.
  3. Endovascular approaches to recanalization in AIS were developed in the 1980s, and recently five major randomized trials (MR CLEAN, ESCAPE, SWIFT-PRIME, EXTEND-IA, and REVASCAT) showed an overwhelming superior benefit of combining endovascular mechanical thrombectomy (MT) with IV-rtPA over IV-rtPA alone.
  4. Based on available data, the American Heart Association/American Stroke Association guidelines endorsed the use of IV-rtPA in combination with MT in patients with AIS of <6 hours’ duration, with large vessel occlusion (LVO) confirmed with vascular imaging, >18 years of age, National Institutes of Health Stroke Scale (NIHSS) score >6, and Alberta Stroke Program Early CT score (ASPECTS) >6.
  5. Evidence of the benefit of MT in posterior circulation stroke is from prospective and retrospective patient cohorts, rather than randomized controlled trials. In the future, trials focusing on posterior circulation stroke are needed to establish effective windows and techniques for this group of patients.
  6. The guidelines also recommend use of stent retrievers as the first-line device; however, other devices may be useful in certain situations.
  7. Other recommendations include faster door-to-recanalization time, the angiographic goal of Thrombolysis in Cerebral Infarction (TICI) 2b/3 for better clinical outcomes, and development of comprehensive stroke centers capable of performing MT.
  8. The challenge now is to increase access to MT for acute stroke patients in the shortest time possible by building up the stroke systems of care in the United States and worldwide.

Clinical Topics: Cardiac Surgery, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Vascular Medicine, Aortic Surgery, Lipid Metabolism, Interventions and Imaging, Interventions and Vascular Medicine

Keywords: Cerebral Infarction, Diagnostic Imaging, Endovascular Procedures, Myocardial Ischemia, Stents, Stroke, Thrombectomy, Tissue Plasminogen Activator, Vascular Diseases

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