Beyond the time window of intravenous thrombolysis: standing by or by stenting?

Abstract

Intravenous administration of tissue plasminogen activator within 4.5 h of symptom onset is presently the 'golden rule' for treating acute ischemic stroke. However, many patients miss the time window and others reject this treatment due to a long list of contraindications. Mechanical embolectomy has recently progressed as a potential alternative for treating patients beyond the time window for IV thrombolysis. In this paper, recent progress in mechanical embolectomy, angioplasty, and stenting in acute stroke is reviewed. Despite worries concerning the long-term clinical outcomes and increased risk of intracranial hemorrhage, favorable clinical outcomes may be achieved after mechanical embolectomy in carefully selected patients even 4.5 h after stroke onset. Potential steps should be prepared and attempted in these patients whose opportunity for recovery will elapse in a flash.

Keywords: Angioplasty; Mechanical embolectomy; Stenting.

Fig. 1

A 58-year-old male with aphasia and right hemiparesis reached our hospital 6 h after symptom onset (NIHSS = 15). a A diffusion-weighted image showed a slightly high signal in the left insular area. b Magnetic resonance angiogram. c Digital subtraction angiography demonstrated M1 segment occlusion in the left middle cerebral artery. d Angiogram via a microguide indicated complete patency of the distal middle cerebral artery. e A solitaire stent was deployed (arrowhead). f A final angiogram of the left middle cerebral artery after retrieval of the stent showed complete recanalization of the middle cerebral artery. g CT showed a small infarction in the left internal capsule 18 h after recanalization. The patient was discharged 7 days later with an NIHSS score of 4.