Management of Acute Ischemic Stroke

  • Alex Abou-Chebl
Peripheral Vascular Disease (M Shishehbor, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Peripheral Vascular Disease


Acute stroke affects about 800,000 patients annually in the US and is the leading cause of disability. It is a complex condition with multiple causes and requires comprehensive but rapid evaluation by stroke specialists working in institutions with well-organized stroke systems of care. Acute stroke treatment is focused on early revascularization with intravenous tPA for those with strokes under 3 hours duration or intra-arterial therapy for most others and those who cannot receive tPA. The latter is evolving rapidly with the advent of stent-retriever embolectomy devices that are poised to revolutionize stroke treatment. Recanalization is associated with neurological recovery in 33–50 % of patients. This also means that many patients may have devastating and life-threatening brain injury, which highlights the need for comprehensive care for the prevention and treatment of medical complications, management of cerebral edema and intracerebral hemorrhage.


Acute stroke Cerebral ischemia Intracerebral hemorrhage Thrombolysis Intra-arterial therapy Thrombectomy 



Conflicts of interest: A. Abou-Chebl: has been the Chair DSMB for Codman Inc.; and is on the speakers' bureaus for BMS/Sanofi.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Roger VL, Go AS, Lloyd-Jones DM, et al. Executive summary: heart disease and stroke statistics–2012 update: a report from the American Heart Association. Circulation. 2012;125:188–97.PubMedCrossRefGoogle Scholar
  2. 2.
    Sacco RL, Benjamin EJ, Broderick JP, et al. American Heart Association Prevention Conference. IV. Prevention and Rehabilitation of Stroke. Risk factors. Stroke. 1997;28:1507–17.PubMedCrossRefGoogle Scholar
  3. 3.
    Marler JR, Tilley BC, Lu M, et al. Early stroke treatment associated with better outcome: the NINDS rt-PA stroke study. Neurology. 2000;55:1649–55.PubMedCrossRefGoogle Scholar
  4. 4.
    Hacke W, Donnan G, Fieschi C, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004;363:768–74.PubMedCrossRefGoogle Scholar
  5. 5.
    Demaerschalk BM, Yip TR. Economic benefit of increasing utilization of intravenous tissue plasminogen activator for acute ischemic stroke in the United States. Stroke. 2005;36:2500–3.PubMedCrossRefGoogle Scholar
  6. 6.
    Suzuki S, Saver JL, Scott P, et al. Access to intra-arterial therapies for acute ischemic stroke: an analysis of the US population. AJNR Am J Neuroradiol. 2004;25:1802–6.PubMedGoogle Scholar
  7. 7.
    Cloft HJ, Rabinstein A, Lanzino G, Kallmes DF. Intra-arterial stroke therapy: an assessment of demand and available work force. AJNR Am J Neuroradiol. 2009;30:453–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Sacco RL, Boden-Albala B, Gan R, et al. Stroke incidence among white, black, and Hispanic residents of an urban community: the Northern Manhattan Stroke Study. Am J Epidemiol. 1998;147:259–68.PubMedCrossRefGoogle Scholar
  9. 9.
    Caplan LR, Hennerici M. Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism, and ischemic stroke. Arch Neurol. 1998;55:1475–82.PubMedCrossRefGoogle Scholar
  10. 10.
    Adams HP, Jr., del ZG, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007;38:1655-711.Google Scholar
  11. 11.
    Adams RJ, Albers G, Alberts MJ, et al. Update to the AHA/ASA recommendations for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke. 2008;39:1647–52.PubMedCrossRefGoogle Scholar
  12. 12.
    Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA. 1999;282:2003–11.PubMedCrossRefGoogle Scholar
  13. 13.
    Morgenstern LB, Hemphill III JC, Anderson C, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010;41:2108–29.PubMedCrossRefGoogle Scholar
  14. 14.
    Bederson JB, Connolly Jr ES, Batjer HH, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 2009;40:994–1025.PubMedCrossRefGoogle Scholar
  15. 15.
    Johnson ER, McKenzie SW, Sievers A. Aspiration pneumonia in stroke. Arch Phys Med Rehabil. 1993;74:973–6.PubMedGoogle Scholar
  16. 16.
    Teasell RW, McRae M, Marchuk Y, Finestone HM. Pneumonia associated with aspiration following stroke. Arch Phys Med Rehabil. 1996;77:707–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Lin K, Do KG, Ong P, et al. Perfusion CT improves diagnostic accuracy for hyperacute ischemic stroke in the 3-hour window: study of 100 patients with diffusion MRI confirmation. Cerebrovasc Dis. 2009;28:72–9.PubMedCrossRefGoogle Scholar
  18. 18.
    •• Lansberg MG, Straka M, Kemp S, et al. MRI profile and response to endovascular reperfusion after stroke (DEFUSE 2): a prospective cohort study. Lancet Neurol. 2012;11:860-7. The first prospective study to show that patients with ischemic penumbra who are treated with IAT fair much better than those without a penumbra.Google Scholar
  19. 19.
    • Abou-Chebl A. Endovascular treatment of acute ischemic stroke may be safely performed with no time window limit in appropriately selected patients. Stroke 2010;41:1996-2000. The first study to compare patients treated beyond 6 hours with those treated under 6 hours and to show the same good outcomes if patients are selected with perfusion imaging, dispelling the myth of an absolute time-window for stroke treatment.Google Scholar
  20. 20.
    Duke RJ, Bloch RF, Turpie AG, Trebilcock R, Bayer N. Intravenous heparin for the prevention of stroke progression in acute partial stable stroke. Ann Intern Med. 1986;105:825–8.PubMedGoogle Scholar
  21. 21.
    CAST: randomised placebo-controlled trial of early aspirin use in 20,000 patients with acute ischaemic stroke. CAST (Chinese Acute Stroke Trial) Collaborative Group. Lancet 1997;349:1641-49.Google Scholar
  22. 22.
    The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group. Lancet 1997;349:1569-81.Google Scholar
  23. 23.
    Abou-Chebl A, Vora N, Yadav JS. Safety of angioplasty and stenting without thrombolysis for the treatment of early ischemic stroke. J Neuroimaging. 2009;19:139–43.PubMedCrossRefGoogle Scholar
  24. 24.
    Adams Jr HP, Effron MB, Torner J, et al. Emergency administration of abciximab for treatment of patients with acute ischemic stroke: results of an international phase III trial: Abciximab in Emergency Treatment of Stroke Trial (AbESTT-II). Stroke. 2008;39:87–99.PubMedCrossRefGoogle Scholar
  25. 25.
    Abou-Chebl A, Bajzer CT, Krieger DW, Furlan AJ, Yadav JS. Multimodal therapy for the treatment of severe ischemic stroke combining GPIIb/IIIa antagonists and angioplasty after failure of thrombolysis. Stroke. 2005;36:2286–8.PubMedCrossRefGoogle Scholar
  26. 26.
    Qureshi AI, Harris-Lane P, Kirmani JF, et al. Intra-arterial reteplase and intravenous abciximab in patients with acute ischemic stroke: an open-label, dose-ranging, phase I study. Neurosurgery. 2006;59:789–96.PubMedCrossRefGoogle Scholar
  27. 27.
    Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995;333:1581-7.Google Scholar
  28. 28.
    Albers GW, Clark WM, Madden KP, Hamilton SA. ATLANTIS trial: results for patients treated within 3 hours of stroke onset. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. Stroke. 2002;33:493–5.PubMedCrossRefGoogle Scholar
  29. 29.
    Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359:1317–29.PubMedCrossRefGoogle Scholar
  30. 30.
    Wolpert SM, Bruckmann H, Greenlee R, Wechsler L, Pessin MS, del Zoppo GJ. Neuroradiologic evaluation of patients with acute stroke treated with recombinant tissue plasminogen activator. The rt-PA Acute Stroke Study Group. AJNR Am J Neuroradiol. 1993;14:3–13.PubMedGoogle Scholar
  31. 31.
    Katzan IL, Hammer MD, Furlan AJ, Hixson ED, Nadzam DM. Quality improvement and tissue-type plasminogen activator for acute ischemic stroke: a Cleveland update. Stroke. 2003;34:799–800.PubMedCrossRefGoogle Scholar
  32. 32.
    Alberts MJ, Hademenos G, Latchaw RE, et al. Recommendations for the establishment of primary stroke centers. Brain Attack Coalition. JAMA. 2000;283:3102–9.PubMedCrossRefGoogle Scholar
  33. 33.
    Alberts MJ, Latchaw RE, Jagoda A, et al. Revised and updated recommendations for the establishment of primary stroke centers: a summary statement from the brain attack coalition. Stroke. 2011;42:2651–65.PubMedCrossRefGoogle Scholar
  34. 34.
    Alberts MJ, Latchaw RE, Selman WR, et al. Recommendations for comprehensive stroke centers: a consensus statement from the Brain Attack Coalition. Stroke. 2005;36:1597–616.PubMedCrossRefGoogle Scholar
  35. 35.
    Qureshi AI, Suri MF, Nasar A, et al. Thrombolysis for ischemic stroke in the United States: data from National Hospital Discharge Survey 1999-2001. Neurosurgery. 2005;57:647–54.PubMedCrossRefGoogle Scholar
  36. 36.
    Smith WS, Sung G, Starkman S, et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke. 2005;36:1432–8.PubMedCrossRefGoogle Scholar
  37. 37.
    Bose A, Henkes H, Alfke K, et al. The Penumbra System: a mechanical device for the treatment of acute stroke due to thromboembolism. AJNR Am J Neuroradiol. 2008;29:1409–13.PubMedCrossRefGoogle Scholar
  38. 38.
    Smith WS, Sung G, Saver J, et al. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke. 2008;39:1205–12.PubMedCrossRefGoogle Scholar
  39. 39.
    The Interventional Management of Stroke (IMS) II Study. Stroke 2007;38:2127-2135.Google Scholar
  40. 40.
    Costalat V, Machi P, Lobotesis K, et al. Rescue, combined, and stand-alone thrombectomy in the management of large vessel occlusion stroke using the solitaire device: a prospective 50-Patient Single-Center Study: Timing, Safety, and Efficacy. Stroke 2011 May 19.Google Scholar
  41. 41.
    Katzan IL, Masaryk TJ, Furlan AJ, et al. Intra-arterial thrombolysis for perioperative stroke after open heart surgery. Neurology. 1999;52:1081–4.PubMedCrossRefGoogle Scholar
  42. 42.
    Nogueira RG, Smith WS. Safety and efficacy of endovascular thrombectomy in patients with abnormal hemostasis: pooled analysis of the MERCI and multi MERCI trials. Stroke. 2009;40:516–22.PubMedCrossRefGoogle Scholar
  43. 43.
    Meyers PM, Schumacher HC, Higashida RT, et al. Indications for the performance of intracranial endovascular neurointerventional procedures: a scientific statement from the American Heart Association Council on Cardiovascular Radiology and Intervention, Stroke Council, Council on Cardiovascular Surgery and Anesthesia, Interdisciplinary Council on Peripheral Vascular Disease, and Interdisciplinary Council on Quality of Care and Outcomes Research. Circulation. 2009;119:2235–49.PubMedCrossRefGoogle Scholar
  44. 44.
    Barnwell SL, Clark WM, Nguyen TT, O'Neill OR, Wynn ML, Coull BM. Safety and efficacy of delayed intraarterial urokinase therapy with mechanical clot disruption for thromboembolic stroke. AJNR Am J Neuroradiol. 1994;15:1817–22.PubMedGoogle Scholar
  45. 45.
    Jovin TG, Liebeskind DS, Gupta R, et al. Imaging-based endovascular therapy for acute ischemic stroke due to proximal intracranial anterior circulation occlusion treated beyond 8 hours from time last seen well: retrospective multicenter analysis of 237 consecutive patients. Stroke. 2011;42:2206–11.PubMedCrossRefGoogle Scholar
  46. 46.
    •• Saver JL, Jahan R, Levy EI, et al. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet 2012;380:1241-9. A randomized trial that compared the Merci™ retriever with a stent-retriever that was stopped early due to a marked benefit in recanalization, safety, good outcomes, and mortality in favor of the latest generation device (Solitaire FR™).Google Scholar
  47. 47.
    •• Nogueira RG, Lutsep HL, Gupta R, et al. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet 2012;380:1231-40. The second randomized trial that showed superiority of a stent-retriever over the older Merci™ embolectomy device. Google Scholar
  48. 48.
    Jovin TG, Gupta R, Uchino K, et al. Emergent stenting of extracranial internal carotid artery occlusion in acute stroke has a high revascularization rate. Stroke. 2005;36:2426–30.PubMedCrossRefGoogle Scholar
  49. 49.
    Gupta R, Tayal AH, Levy EI, et al. Intra-arterial thrombolysis or stent placement during endovascular treatment for acute ischemic stroke leads to the highest recanalization rate: results of a multicenter retrospective study. Neurosurgery. 2011;68:1618–22.PubMedCrossRefGoogle Scholar
  50. 50.
    Levy EI, Rahman M, Khalessi AA, et al. Midterm clinical and angiographic follow-up for the first Food and Drug Administration-approved prospective, Single-Arm Trial of Primary Stenting for Stroke: SARIS (Stent-Assisted Recanalization for Acute Ischemic Stroke). Neurosurgery. 2011;69:915–20.PubMedCrossRefGoogle Scholar
  51. 51.
    Adams Jr HP, Brott TG, Furlan AJ, et al. Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association. Circulation. 1996;94:1167–74.PubMedCrossRefGoogle Scholar
  52. 52.
    Juttler E, Schwab S, Schmiedek P, et al. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke. 2007;38:2518–25.PubMedCrossRefGoogle Scholar
  53. 53.
    Rahme R, Zuccarello M, Kleindorfer D, Adeoye OM, Ringer AJ. Decompressive hemicraniectomy for malignant middle cerebral artery territory infarction: is life worth living? J Neurosurg. 2012;117:749–54.PubMedCrossRefGoogle Scholar
  54. 54.
    Zhao J, Su YY, Zhang Y, et al. Decompressive hemicraniectomy in malignant middle cerebral artery infarct: a randomized controlled trial enrolling patients up to 80 years old. Neurocrit Care. 2012;17:161–71.PubMedCrossRefGoogle Scholar
  55. 55.
    McKenna A, Wilson CF, Caldwell SB, Curran D. Functional outcomes of decompressive hemicraniectomy following malignant middle cerebral artery infarctions: a systematic review. Br J Neurosurg. 2012;26:310–5.PubMedCrossRefGoogle Scholar
  56. 56.
    Bershad EM, Feen ES, Hernandez OH, Suri MF, Suarez JI. Impact of a specialized neurointensive care team on outcomes of critically ill acute ischemic stroke patients. Neurocrit Care. 2008;9:287–92.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Department of NeurologyUniversity of Louisville School of MedicineLouisvilleUSA

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