Current Treatment Options in Neurology

, Volume 9, Issue 6, pp 463–469

Endovascular treatment of acute stroke


Opinion statement

An obvious treatment goal in patients suffering an acute stroke due to an occlusion of a cerebral vessel is restoring blood flow to ischemic tissue. Studies have shown that recanalization of blood vessels can be achieved through endovascular therapy using either thrombolytics or mechanical clot removal. Because the clinical response to intravenous thrombolysis is exquisitely time-dependent, patients should be treated as soon as possible. Intravenous thrombolysis is the initial therapy in patients who present within 3 hours of stroke onset. Endovascular therapy should be considered for patients with large-vessel occlusions who are not candidates for intravenous thrombolysis or who do not recanalize after intravenous thrombolysis.


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References and Recommended Reading

  1. 1.
    Furlan AJ, Higashida R, Wechsler LR, et al.: Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA 1999, 282:2003–2011.PubMedCrossRefGoogle Scholar
  2. 2.
    Lee KY, Han SW, Kim SH, et al.: Early recanalization after intravenous administration of recombinant tissue plasminogen activator as assessed by pre-and post-thrombolytic angiography in acute ischemic stroke patients. Stroke 2007, 38:192–193.PubMedCrossRefGoogle Scholar
  3. 3.
    Rajajee V, Kidwell C, Starkman S, et al.: Early MRI and outcomes of untreated patients with mild or improving ischemic stroke. Neurology 2006, 67:980–984.PubMedCrossRefGoogle Scholar
  4. 4.
    Smith WS, Tsao JW, Billings ME, et al.: Prognostic significance of angiographically confirmed large vessel intracranial occlusion in patients presenting with acute brain ischemia. Neurocrit Care 2006, 4:14–17.PubMedCrossRefGoogle Scholar
  5. 5.
    Garg N, Eshkar N, Tanenbaum L, et al.: Computed tomography angiographic correlates of early computed tomography signs in acute ischemic stroke. J Neuroimaging 2004, 14:242–245.PubMedCrossRefGoogle Scholar
  6. 6.
    Derex L, Nighoghossian N, Hermier M, et al.: Early detection of cerebral arterial occlusion on magnetic resonance angiography: predictive value of the baseline NIHSS score and impact on neurological outcome. Cerebrovasc Dis 2002, 13:225–229.PubMedCrossRefGoogle Scholar
  7. 7.
    Fischer U, Arnold M, Nedeltchev K, et al.: NIHSS score and arteriographic findings in acute ischemic stroke. Stroke 2005, 36:2121–2125.PubMedCrossRefGoogle Scholar
  8. 8.
    Weimar C, Mieck T, Buchthal J, et al.: Neurologic worsening during the acute phase of ischemic stroke. Arch Neurol 2005, 62:393–397.PubMedCrossRefGoogle Scholar
  9. 9.
    Verro P, Tanenbaum LN, Borden NM, et al.: CT angiography in acute ischemic stroke: preliminary results. Stroke 2002, 33:276–278.PubMedCrossRefGoogle Scholar
  10. 10.
    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, 333:1581–1587.CrossRefGoogle Scholar
  11. 11.
    Barber PA, Zhang J, Demchuk AM, et al.: Why are stroke patients excluded from TPA therapy? An analysis of patient eligibility. Neurology 2001, 56:1015–1020.PubMedGoogle Scholar
  12. 12.
    Katzan IL, Hammer MD, Hixson ED, et al.: Utilization of intravenous tissue plasminogen activator for acute ischemic stroke. Arch Neurol 2004, 61:346–350.PubMedCrossRefGoogle Scholar
  13. 13.
    Hill MD, Kent DM, Hinchey J, et al.: Sex-based differences in the effect of intra-arterial treatment of stroke: analysis of the PROACT-2 study. Stroke 2006, 37:2322–2325.PubMedCrossRefGoogle Scholar
  14. 14.
    Kase CS, Furlan AJ, Wechsler LR, et al.: Cerebral hemorrhage after intra-arterial thrombolysis for ischemic stroke: the PROACT II trial. Neurology 2001, 57:1603–1610.PubMedGoogle Scholar
  15. 15.
    Adams HP Jr, Adams RJ, Brott T, et al.: Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. Stroke 2003, 34:1056–1083.PubMedCrossRefGoogle Scholar
  16. 16.
    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, 36:1432–1438.PubMedCrossRefGoogle Scholar
  17. 17.
    Smith WS: Safety of mechanical thrombectomy and intravenous tissue plasminogen activator in acute ischemic stroke. Results of the multi Mechanical Embolus Removal in Cerebral Ischemia (MERCI) trial, part I. AJNR Am J Neuroradiol 2006, 27:1177–1182.PubMedGoogle Scholar
  18. 18.
    Wolpert SM, Bruckmann H, Greenlee R, et al.: 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
  19. 19.
    Mori E, Yoneda Y, Tabuchi M, et al.: Intravenous recombinant tissue plasminogen activator in acute carotid artery territory stroke. Neurology 1992, 42:976–982.PubMedGoogle Scholar
  20. 20.
    del Zoppo GM, Poeck K, Pessin MS, et al.: Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke. Ann Neurol 1992, 32:78–86.PubMedCrossRefGoogle Scholar
  21. 21.
    Alexandrov AV, Molina CA, Grotta JC, et al.: Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke. N Engl J Med 2004, 351:2170–2178.PubMedCrossRefGoogle Scholar
  22. 22.
    Combined intravenous and intra-arterial recanalization for acute ischemic stroke: the Interventional Management of Stroke Study. Stroke 2004, 35:904–911.CrossRefGoogle Scholar
  23. 23.
    The Interventional Management of Stroke (IMS) II Study. Stroke 2007, 38:2127–2135.Google Scholar
  24. 24.
    Albers GW, Thijs VN, Wechsler LR, et al.: Magnetic resonance imaging profiles predict clinical response to early reperfusion: the diffusion and perfusion imaging evaluation for understanding stroke evolution (DEFUSE) study. Ann Neurol 2006, 60:508–517.PubMedCrossRefGoogle Scholar
  25. 25.
    Kloska SP, Dittrich R, Fischer T, et al.: Perfusion CT in acute stroke: prediction of vessel recanalization and clinical outcome in intravenous thrombolytic therapy. Eur Radiol 2007, In press.Google Scholar
  26. 26.
    Schaefer PW, Roccatagliata L, Ledezma C, et al.: Firstpass quantitative CT perfusion identifies thresholds for salvageable penumbra in acute stroke patients treated with intra-arterial therapy. AJNR Am J Neuroradiol 2006, 27:20–25.PubMedGoogle Scholar
  27. 27.
    Gupta R, Yonas H, Gebel J, et al.: Reduced pretreatment ipsilateral middle cerebral artery cerebral blood flow is predictive of symptomatic hemorrhage post-intra-arterial thrombolysis in patients with middle cerebral artery occlusion. Stroke 2006, 37:2526–2530.PubMedCrossRefGoogle Scholar
  28. 28.
    Jovin TG, Gupta R, Horowitz MB, et al.: Pretreatment ipsilateral regional cortical blood flow influences vessel recanalization in intra-arterial thrombolysis for MCA occlusion. AJNR Am J Neuroradiol 2007, 28:164–167.PubMedGoogle Scholar
  29. 29.
    Jovin TG, Yonas H, Gebel JM, et al.: The cortical ischemic core and not the consistently present penumbra is a determinant of clinical outcome in acute middle cerebral artery occlusion. Stroke 2003, 34:2426–2433.PubMedCrossRefGoogle Scholar
  30. 30.
    Brandt T, von Kummer R, Muller-Kuppers M, et al.: Thrombolytic therapy of acute basilar artery occlusion. Variables affecting recanalization and outcome. Stroke 1996, 27:875–881.PubMedGoogle Scholar
  31. 31.
    Arnold M, Nedeltchev K, Schroth G, et al.: Clinical and radiological predictors of recanalisation and outcome of 40 patients with acute basilar artery occlusion treated with intra-arterial thrombolysis. J Neurol Neurosurg Psychiatry 2004, 75:857–862.PubMedCrossRefGoogle Scholar
  32. 32.
    Brandt T: Diagnosis and thrombolytic therapy of acute basilar artery occlusion: a review. Clin Exp Hypertens 2002, 24:611–622.PubMedCrossRefGoogle Scholar
  33. 33.
    Ezaki Y, Tsutsumi K, Onizuka M, et al.: Retrospective analysis of neurological outcome after intra-arterial thrombolysis in basilar artery occlusion. Surg Neurol 2003, 60:423–429; discussion 429–430.PubMedCrossRefGoogle Scholar
  34. 34.
    Saqqur M, Uchino K, Demchuk AM, et al.: Site of arterial occlusion identified by transcranial Doppler predicts the response to intravenous thrombolysis for stroke. Stroke 2007, 38:948–954.PubMedCrossRefGoogle Scholar
  35. 35.
    Linfante I, Llinas RH, Selim M, et al.: Clinical and vascular outcome in internal carotid artery versus middle cerebral artery occlusions after intravenous tissue plasminogen activator. Stroke 2002, 33:2066–2071.PubMedCrossRefGoogle Scholar
  36. 36.
    Jansen O, von Kummer R, Forsting M, et al.: Thrombolytic therapy in acute occlusion of the intracranial internal carotid artery bifurcation. AJNR Am J Neuroradiol 1995, 16:1977–1986.PubMedGoogle Scholar
  37. 37.
    Flint AC, Duckwiler GR, Budzik RF, et al.: Mechanical thrombectomy of intracranial internal carotid occlusion: pooled results of the MERCI and Multi MERCI Part I trials. Stroke 2007, 38:1274–1280.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  1. 1.University of WashingtonSeattleUSA

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