Status of endovascular interventions to treat acute ischemic stroke

Acute stroke is a major component of neurology and one of few neurologic emergencies. Despite many efforts to increase treatment of acute ischemic stroke, we are still not able to treat a significant percentage of patients with intravenous tPA, typically because of time restrictions. Unfortunately, many patients do not present to medical attention within the short window for tPA administration. In addition, there are numerous contraindications for tPA, which make more patients ineligible. Endovascular treatment for acute ischemic stroke may help to expand the number of patients treated by extending the time window beyond the 3 to 4.5 hour constraints of IV tPA, and including patients with tPA contraindications such as use of oral anticoagulants. However, several recent studies have raised questions regarding the utility and efficacy of these procedures. These studies should not discourage endovascular treatment of acute stroke, but should lead us to ask more questions and be proactive in seeking answers, and should make us carefully select the patient population to receive the treatment. Future studies should take advantage of the lessons learned from these recent trials, including the importance of using vascular imaging for inclusion criteria, and of utilizing the latest and most advanced devices and techniques. Endovascular therapy will continue to evolve into what will hopefully be a clinically significant alternative therapy for acute ischemic stroke.