Treatment of acute ischemic stroke: beyond thrombolysis and supportive care

Abstract

The initial therapeutic approach to acute ischemic stroke consists of thrombolytic therapy and early initiation of supportive care, usually commenced prior to the determination of the underlying stroke etiology. Varying stroke mechanisms may call for specific, etiology-based treatment. The majority of strokes result from cardioembolism, large-vessel atherothromboembolism, and small-vessel occlusive disease. There are scant data to support the use of acute anticoagulation therapy over anti-platelet therapy in cardioembolic stroke and large-vessel atherosclerosis, although it may be reasonable in a certain subset of patients. However, augmentation of blood flow with early surgery, stenting, or induced hypertension, may play a role in patients with large artery stenosis. The less commonly identified stroke mechanisms may warrant special consideration in treatment. Controversy remains regarding the optimal anti-thrombotic treatment of arterial dissection. Reversible cerebral vasoconstriction syndrome may benefit from therapy with calcium channel blockers, high-dose steroids, or magnesium, although spontaneous recovery may occur. Inflammatory vasculopathies, such as isolated angiitis of the central nervous system and temporal arteritis, require prompt diagnosis as the mainstay of therapy is immunosuppression. Cerebral venous thrombosis is a rare cause of stroke, but one that needs early identification and treatment with anticoagulation. Rapid determination of stroke mechanism is essential for making these critical early treatment decisions.

Fig. 1

(a) Computed tomographic head scan without contrast showing right middle cerebral artery territory infarction. (b) Hemorrhagic conversion of the same infarct, with mass effect and midline shift

Fig. 2

Magnetic resonance image with contrast demonstrating bilateral vertebral artery dissections with wall hematomas and stenosis of the left vertebral artery

Fig. 3

Conventional angiogram demonstrating segmental narrowing in reversible cerebral vasoconstriction syndrome

Fig. 4

(a) Venous angiogram showing large filling defects and extensive thrombus in the right transverse sinus, torcula, and superior sagittal sinus. (b) Image taken after mechanical thrombolysis demonstrating partial vessel recanalization, with improved flow and decreased clot burden