Acute Stroke Intervention | Ten Points to Remember

Prabhakaran P, Ruff I, Bernstein RA.
Acute Stroke Intervention: A Systematic Review. JAMA 2015;313:1451-1462.

The following are 10 points to remember about acute stroke interventions:

  1. During an acute ischemic stroke, there is a core of tissue that has been irreversibly damaged by ischemia. This core is surrounded by the ischemic penumbra, tissue that is hypoperfused and at risk of permanent injury, but with reperfusion, could be salvaged and return to normal function. The goal of acute stroke treatment is to restore flow to the ischemic penumbra.
  2. Intravenous (IV) tissue plasminogen activator (tPA) is the standard of care for patients with acute ischemic stroke if it can be given within 4.5 hours of the last known normal time. IV tPA reduces the odds of disability after ischemic stroke.
  3. While IV tPA is effective for all ischemic stroke subtypes, patients with large artery occlusion often do not recanalize after IV tPA, and these patients tend to have poor functional outcomes, even when they are treated with IV tPA.
  4. Intra-arterial thrombolysis can be performed after IV tPA administration, and is an option for patients with contraindications to IV tPA.
  5. Techniques for intra-arterial thrombolysis have evolved over the years from chemical thrombolysis using prourokinase, to coil retrievers and mechanical disruption with aspiration, to stent retrievers. With each generation of device, reperfusion rates have improved.
  6. Recent trials of stent retrievers, when compared with medical treatment, showed that patients treated with these devices had improved functional outcomes.
  7. Intra-arterial thrombolysis should be generally completed within 6 hours of the last known normal time. While recent trials allowed for expanded time windows, the majority of patients enrolled in these trials were treated within 6 hours.
  8. Patients who are candidates for intra-arterial treatment should have evidence of a target large vessel occlusion. In addition to a computed tomography angiography, which demonstrated the occlusion, some of the studies of stent retrievers used advanced imaging to select patients based on a pattern of collateral flow or ratio of penumbral to core tissue. These advanced imaging techniques require further study before they can be incorporated into routine practice.
  9. Many patients do not recognize stroke symptoms. This leads to delays in activation of the emergency medical system (EMS); or not using EMS, and presenting directly to the emergency department, which can delay treatment.
  10. Regardless of method of treatment (IV tPA, intra-arterial thrombolysis, or both), rapid treatment is associated with improved outcomes. Stroke systems of care should work to decrease time to treatment.

Keywords: Angiography, Arteries, Emergency Service, Hospital, Infusions, Intravenous, Standard of Care, Stents, Stroke, Time-to-Treatment, Tissue Plasminogen Activator, Tomography, Urokinase-Type Plasminogen Activator

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