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Acute Ischemic Stroke: Recent Advances in Reperfusion Treatment
Quick Takes
- “Time is brain.” Shorter times to thrombolysis and thrombectomy are associated with lower degrees of disability after stroke.
- Eligible patients should receive thrombolysis, regardless of whether they may also be candidates for mechanical thrombectomy for large vessel occlusion.
- Patients with proximal large vessel occlusion who can be treated within 6 hours from last known normal should receive mechanical thrombectomy in most cases.
- For some individuals with basilar artery occlusion or anterior circulation occlusion and favorable advanced imaging, the window for thrombectomy may be as long as 24 hours.
Study Questions:
What is the current knowledge of acute ischemic stroke diagnosis and treatment?
Methods:
This is a review paper, which summarizes the latest evidence from randomized clinical trials and prospective registries with a focus on endovascular treatment using stent retrievers, aspiration catheters, thrombolytics, and carotid stenting in selected patients.
Results:
A multidisciplinary “stroke code” approach is important for ensuring rapid treatment of eligible acute ischemic stroke patients with thrombolysis and/or thrombectomy. As evidence of the importance of time to treatment, mobile stroke units are emerging in some communities to allow for rapid triage and treatment of ischemic stroke patients. Patients who are eligible for intravenous thrombolysis should receive treatment as quickly as possible, regardless of whether they may also be candidates for mechanical thrombectomy for a proximal intracranial occlusion. The role of intra-arterial thrombolysis in acute stroke remains unclear. High-quality randomized trial data are needed to clarify whether thrombectomy is indicated for patients with more distal (medium vessel) occlusions. In most centers, mechanical thrombectomy is offered to patients with basilar artery occlusion out to 24 hours from last known normal given how devastating the disease may be without treatment.
Conclusions:
Acute stroke treatment has evolved dramatically over the last 10 years. In the realm of thrombolysis, tenecteplase will likely replace alteplase at most centers given its ease-of-administration and encouraging safety data. Mechanical thrombectomy for many patents with large vessel occlusion is now the standard of care. Advanced imaging modalities allow for the selection of patients with a large territory of potentially salvageable tissue and minimal core infarct in whom the acute treatment window may be safely expanded.
Perspective:
Acute ischemic stroke treatment is a rapidly evolving field with an exciting future. Despite a longer treatment window for many patients, speedy treatment remains key: “Time is brain.”
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Vascular Medicine, Aortic Surgery, Lipid Metabolism, Novel Agents, Interventions and Imaging, Interventions and Vascular Medicine
Keywords: Brain Infarction, Coronary Occlusion, Diagnostic Imaging, Endovascular Procedures, Ischemic Stroke, Stents, Stroke, Reperfusion, Tenecteplase, Thrombectomy, Thrombolytic Therapy, Tissue Plasminogen Activator, Treatment Outcome, Triage, Vascular Diseases
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