Endovascular Reperfusion Strategies for Acute Stroke

Papanagiotou P, White CJ.
Endovascular Reperfusion Strategies for Acute Stroke. JACC Cardiovasc Interv 2016;Jan 20:[Epub ahead of print].

The following are key points to remember from this state-of-the-art paper on endovascular reperfusion strategies for acute stroke:

  1. Stroke is the most common cause of permanent disability, the second most common cause of dementia, and the third most common cause of death in the Western world.
  2. The primary principle driving treatment of ischemic stroke is that “time is brain.” If blood flow is rapidly restored, some ischemic brain tissue will be saved. This puts a premium on the rapid assessment of patients presenting with stroke.
  3. Previous trials of endovascular therapy included the intracranial administration of thrombolysis and the use of early-generation mechanical thrombectomy devices.
  4. A large number of prospective trials studying mechanical thrombectomy for acute ischemic stroke that predate “stent retriever” devices have been negative or inconclusive.
  5. Between December 2014 and April 2015, five multicenter randomized clinical trials were published with positive results with endovascular therapy. The major differences between these positive endovascular trials and past trials were the use of computed tomography angiography (CTA) to select patients with proximal intracranial occlusion and the use of stent retrievers for thrombectomy in the majority of cases.
  6. Imaging helps identify target intracranial thrombi and measures the extent of salvageable brain tissue. Imaging the brain and the vasculature that supplies it is therefore a vital first step in evaluating patients with acute ischemic stroke. A comprehensive evaluation may be performed with CTA or magnetic resonance imaging.
  7. If an occlusion of a large intracranial vessel is found, the decision to perform endovascular therapy is based on the clinical condition of the patient, the time window (up to 6 hours after stroke onset), as well as imaging criteria of the CTA and CT perfusion (presence of leptomeningeal collaterals and of ischemic penumbra).
  8. Stent retrievers are self-expandable stentlike devices that are fully retrievable. Therefore, these devices combine the advantages of prompt flow restoration and mechanical thrombectomy. The improved clinical outcome with flow-restoration devices is due to fast and effective clot removal and the possibility of restoring flow.
  9. Complications that can occur during or after the procedure include distal embolization to the same or other vessel territories, dissection of the arteries, and subarachnoid or intracerebral hemorrhage.
  10. The current endovascular reperfusion therapies allow high recanalization rates, high rates of favorable clinical outcomes, and low complication rates. However, to optimize clinical results, image-guided patient selection and the use of an optimized stroke management protocol are required.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Aortic Surgery, Interventions and Imaging, Angiography, Computed Tomography, Magnetic Resonance Imaging, Nuclear Imaging, Sleep Apnea

Keywords: Angiography, Cerebral Hemorrhage, Dementia, Endovascular Procedures, Magnetic Resonance Imaging, Prednisolone, Reperfusion, Stents, Stroke, Thrombectomy, Tomography, Tomography, X-Ray Computed, Vascular Diseases

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