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Recanalization therapy for acute ischemic stroke, part 1: surgical embolectomy and chemical thrombolysis

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Abstract

Cerebral revascularization approaches for acute ischemic stroke greatly expanded during the past decade. Many new revascularization strategies are currently being assessed, while others continue to gain in popularity, offering hope to those with an otherwise refractory disease. We discuss historical and current progress toward successful recanalization, as well as the efforts being made to develop a safe and efficacious method of revascularization in the treatment of acute ischemic stroke.

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Acknowledgments

We thank David Peace for preparing the illustrations.

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Authors and Affiliations

  1. Department of Neurosurgery, University of Florida, Gainesville, FL, USA

    Saeed Ansari, Maryam Rahman, Brian L. Hoh & J Mocco

  2. Department of Neurology, University of Florida, Gainesville, FL, USA

    Michael F. Waters

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  1. Saeed Ansari
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Atos Alves de Sousa, Belo Horizonte, Brazil

This paper is a very good survey on recanalization therapy for acute ischemic stroke, and, in my opinion, the authors are to be congratulated for their great work.

They described, in a very clear way, the evolution of the recanalization therapy, from surgical embolectomy to chemical thrombolysis, reviewing the most relevant papers and trials of the literature.

As stroke is the third most common cause of death in industrialized countries and one of the most important causes of disability in the adult population, it is fundamental to have this pathology discussed in all major neurological and neurosurgical journals. This is very helpful for professionals involved in the treatment of acute stroke to orientate the population in general and to convince authorities responsible for health care and hospital directors to invest in stroke centers around the world.

Giuseppe Lanzino, Rochester, USA

The advent of intravenous t-PA for acute ischemic stroke has revolutionalized the treatment of this condition. Before the “t-PA” era, a nihilistic approach toward the patient with acute ischemic stroke was routine. The understanding of the pathophysiology of cerebral ischemia and the recognition of the concept of “ischemic penumbra” has led the way to the development of effective therapies for this disabling condition. After demonstration of the effectiveness of intravenous lytic therapy and in parallel with significant advances in endovascular techniques, intra-arterial delivery was proposed to deliver locally the fibrinolytic drug at the site of clot obstruction. In theory, this approach has the advantage of decreasing the incidence of systemic and local complications as the drug is delivered locally and lower doses are required. Moreover, the ability to deliver the antifibrinolytic locally would, in theory, increase the ability of the drug to lyse the clot. Intra-arterial delivery has extended the “therapeutic” window so that more patients can potentially benefit from this therapy. The PROACT study provides evidence from a randomized study that, in properly selected patients, intra-arterial fibrinolytic delivery improves outcome. With intravenous and intra-arterial delivery and, as seen in the accompanying study, with newer mechanical technologies, we can consistently re-canalize an acutely occluded blood vessel. Further improvements in this field will most likely come from better selection of patients who may benefit from aggressive therapy (perfusion studies, etc.) and from the availability of neuroprotective therapies to “limit” the extent of permanent damage while waiting for recanalization.

Carlo Schaller, Geneva, Switzerland

This is part 1 of a comprehensive review on the treatment of ischemic cerebral stroke. The authors provide an epidemiological and historical overview on the matter. Largely, this is being performed in a chronological manner. It is very interesting to read as, due to the comprehensive presentation, one can clearly feel the intense and multi-disciplinary efforts in order to cope with this threatening pathological entity. They refer to early (micro)surgical attempts as well to treat cerebral ischemic stroke. These efforts were merely heroic in nature and born out of despair in view of the almost unanimously dismal prognosis of stroke only few decades ago. They go on with an elaborate explanation and an overview on the more recent and further attempts by neurologists in order to restore brain circulation by intra-arterial and/or intravenous administration of thrombolytic agents. Thereby, the interested reader may learn about the most important studies on the subject, as the authors are highlighting also the difficulties in order to advance stroke treatment and the burden which comes with this detrimental disease in general. It becomes quite clear that treatment of stroke requires not only rapid judgement from the very first minute on (time is brain!) with a functioning referral system, which should assure that patients are being transferred to competent centers with a particular focus on the treatment of neurovascular disease. This should include high-end imaging, neuroendovascular diagnostics and treatment, and an adequate setting for clinical monitoring on dedicated stroke units, where treatment efforts may be followed by particular ultrasound technology as well. The role of US neurosurgeons has to be redefined in view of all these new developments. Whereas, in acute stroke, our role relates to mere overall participation in patient care, e.g., by surveillance of intracranial pressure, or by performance of hemicraniectomies in selected patients, I see a resurge of indications for potential preventive measures by the application of cerebral revascularization according to more subtle inclusion criteria and refined techniques. Cerebral stroke is a terrible burden to patients and to society. Unfortunately, in most countries, one is far from having achieved the same intensity of care and the same speed of care which is applied in myocardial infarction. This has of course historical reasons, but this is, in part, also due to the fact that so many different medical specialties are involved in neurovascular stroke, which can exert their capacity only in very fine-tuned settings and in dedicated centers of clinical neurosciences. A lot of work lies ahead of us in order to convince the relevant political authorities. The authors are to be commended for having submitted such a clear and yet elaborated review, and for stipulating the discussion on the future of treatment of cerebral stroke.

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Ansari, S., Rahman, M., Waters, M.F. et al. Recanalization therapy for acute ischemic stroke, part 1: surgical embolectomy and chemical thrombolysis. Neurosurg Rev 34, 1–9 (2011). https://doi.org/10.1007/s10143-010-0293-2

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