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. 2015 Oct;6(5):345-54.
doi: 10.1007/s12975-015-0419-5. Epub 2015 Aug 29.

Critical early thrombolytic and endovascular reperfusion therapy for acute ischemic stroke victims: a call for adjunct neuroprotection

Paul A Lapchak  1
Affiliations

Critical early thrombolytic and endovascular reperfusion therapy for acute ischemic stroke victims: a call for adjunct neuroprotection

Paul A Lapchak. Transl Stroke Res. 2015 Oct.

Abstract

Today, there is an enormous amount of excitement in the field of stroke victim care due to the recent success of MR. CLEAN, SWIFT PRIME, ESCAPE, EXTEND-IA, and REVASCAT endovascular trials. Successful intravenous (IV) recombinant tissue plasminogen activator (rt-PA) clinical trials [i.e., National Institute of Neurological Disorders and Stroke (NINDS) rt-PA trial, Third European Cooperative Acute Stroke Study (ECASSIII), and Third International Stroke study (IST-3)] also need to be emphasized. In the recent endovascular and thrombolytic trials, there is statistically significant improvement using both the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Score (mRS) scale, but neither approach promotes complete recovery in patients enrolled within any particular NIHSS or mRS score tier. Absolute improvement (mRS 0-2 at 90 days) with endovascular therapy is 13.5-31 %, whereas thrombolytics alone also significantly improve patient functional independence, but to a lesser degree (NINDS rt-PA trial 13 %). This article has 3 main goals: (1) first to emphasize the utility and cost-effectiveness of rt-PA to treat stroke; (2) second to review the recent endovascular trials with respect to efficacy, safety, and cost-effectiveness as a stroke treatment; and (3) to further consider and evaluate strategies to develop novel neuroprotective drugs. A thesis will be put forth so that future stroke trials and therapy development can optimally promote recovery so that stroke victims can return to "normal" life.

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Conflict of interest statement

Conflict of Interest Statement & Disclosure: PAL serves as Editor-in-Chief of the Journal of Neurology & Neurophysiology and Associate Editor of Translational Stroke Research. The scientific content of this work was not directly supported by the National Institutes of Health (NIH), National Institute of Neurodegenerative Disease and Stroke (NINDS) or any other funding source external to Cedars-Sinai Medical Center. PAL was supported in part by a U01 Translational research grant NS060685 for initial concepts of this article.

Figures

Figure 1
Figure 1
NINDS rt-PA trial 3 months outcome (NIHSS scores)
Figure 2
Figure 2
NINDS rt-PA trial 3 months outcome (mRS scores)
Figure 3
Figure 3
ECASS III trial 3 months outcome Intention-to Treat Population (mRS scores)
Figure 4
Figure 4
Embolectomy-Thrombolytic Trials 3 month mRS outcome
Figure 5
Figure 5. Summary of Mechanical Thrombectomy Study Outcomes
A) Bar numbering Left to right: Bar 1- thrombectomy-lytic reperfusion; Bar 2 lytic arm reperfusion; Bar 3- achieving mRS of 0–2; Bar 4- achieving mRS 0–2 wlytic; B) Bar numbering Left to right: Bar 1- thrombectomy sICH; Bar 2- rt-PA arm sICH; Dark Bar 3- thrombectomy mortality rate; Bar 4- mortality rate w/lytic.
Figure 6
Figure 6
Functional Independence After Embolectomy.
See this image and copyright information in PMC

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