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Acute stroke intervention: a systematic review

Shyam Prabhakaran¹, Ilana Ruff¹, Richard A Bernstein¹

¹Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

|April 15, 2015

Insights

Acute ischemic stroke treatment improved with mechanical thrombectomy for proximal artery occlusions. Early reperfusion, including intravenous thrombolysis and thrombectomy, is key for better patient outcomes.

Area of Science:

Neurology
Cardiovascular Medicine
Neurosurgery

Background:

Acute ischemic stroke is a leading cause of death and disability in the US.
Timely reperfusion is critical for improving patient outcomes.

Purpose of the Study:

To review the pathophysiology of acute brain ischemia and infarction.
To evaluate evidence for various stroke reperfusion treatments, including intravenous thrombolysis and mechanical thrombectomy.

Main Methods:

Systematic literature search of MEDLINE (1990-2015).
Included randomized trials, observational studies, guidelines, and reviews.
Analyzed 68 articles covering 108,082 patients.

Main Results:

Intravenous thrombolysis (IV rtPA) is the standard for eligible patients within 4.5 hours.
Mechanical thrombectomy significantly improves outcomes for select patients with proximal artery occlusions.
Earlier reperfusion, by any method, correlates with better clinical outcomes.

Conclusions:

IV rtPA remains the standard of care for acute ischemic stroke within 4.5 hours.
Endovascular therapy offers improved outcomes for specific patients with proximal artery occlusions.
Accelerating reperfusion therapy through organized stroke systems is essential.

Read full analysis

Abstract

Importance:

Acute ischemic stroke is a major cause of mortality and morbidity in the United States. We review the latest data and evidence supporting catheter-directed treatment for proximal artery occlusion as an adjunct to intravenous thrombolysis in patients with acute stroke.

Objective:

To review the pathophysiology of acute brain ischemia and infarction and the evidence supporting various stroke reperfusion treatments.

Evidence Review:

Systematic literature search of MEDLINE databases published between January 1, 1990, and February 11, 2015, was performed to identify studies addressing the role of thrombolysis and mechanical thrombectomy in acute stroke management. Studies included randomized clinical trials, observational studies, guideline statements, and review articles. Sixty-eight articles (N = 108,082 patients) were selected for review.

Findings:

Intravenous thrombolysis is the mainstay of acute ischemic stroke management for any patient with disabling deficits presenting within 4.5 hours from symptom onset. Randomized trials have demonstrated that more patients return to having good function (defined by being independent and having slight disability or less) when treated within 4.5 hours after symptom onset with intravenous recombinant tissue plasminogen activator (IV rtPA) therapy. Mechanical thrombectomy in select patients with acute ischemic stroke and proximal artery occlusions has demonstrated substantial rates of partial or complete arterial recanalization and improved outcomes compared with IV rtPA or best medical treatment alone in multiple randomized clinical trials. Regardless of mode of reperfusion, earlier reperfusion is associated with better clinical outcomes.

Conclusions And Relevance:

Intravenous rtPA remains the standard of care for patients with moderate to severe neurological deficits who present within 4.5 hours of symptom onset. Outcomes for some patients with acute ischemic stroke and moderate to severe neurological deficits due to proximal artery occlusion are improved with endovascular reperfusion therapy. Efforts to hasten reperfusion therapy, regardless of the mode, should be undertaken within organized stroke systems of care.

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