Acute ischaemic stroke: recent advances in reperfusion treatment

Abstract

During the last 5-7 years, tremendous progress was achieved in the reperfusion treatment of acute ischaemic stroke during its first few hours from symptom onset. This review summarizes the latest evidence from randomized clinical trials and prospective registries with a focus on endovascular treatment using stent retrievers, aspiration catheters, thrombolytics, and (in selected patients) carotid stenting. Novel approaches in prehospital (mobile interventional stroke teams) and early hospital (direct transfer to angiography) management are described, and future perspectives ('all-in-one' laboratories with angiography and computed tomography integrated) are discussed. There is reasonable chance for patients with moderate-to-severe acute ischaemic stroke to survive without permanent sequelae when the large-vessel occlusion is removed by means of modern pharmaco-mechanic approach. Catheter thrombectomy is now the golden standard of acute stroke treatment. The role of cardiologists in stroke is expanding from diagnostic help (to reveal the cause of stroke) to acute therapy in those regions where such up-to-date Class I. A treatment is not yet available.

Keywords: Acute stroke; Endovascular; Thrombectomy; Thrombolysis.

Graphical Abstract

Upper part left: angiography of an occluded middle cerebral artery (typical image in an acute anterior circulation stroke). Upper middle: ongoing ischaemia in the brain area, supplied by the occluded artery. Upper right: computed tomography and perfusion computed tomography images in the acute phase of anterior circulation stroke. Lower part left: intravenous thrombolysis is recommended within 4.5 h of symptom onset (if no contraindication is present). Lower middle: endovascular treatment (i.e. thrombectomy with stent retriever and/or aspiration catheter) is recommended within 6 h of symptom onset, irrespective of whether intravenous thrombolysis was given or not. Lower right: Time window for endovascular treatment may be extended up to 24 h from symptom onset when significant penumbra is proven by advanced imaging methods (e.g. perfusion computed tomography). ASPECT, Alberta Stroke Programme Early CT; CT, computed tomography; DSA, digital subtraction angiography; EVT, endovascular treatment; IVT, intravenous thrombolysis; LVO, large-vessel occlusion; NIHSS, National Institutes of Health Stroke Scale.

Figure 1

Drip-and-ship (presentation to non-thrombectomy centre followed by interhospital transfer to thrombectomy centre): emergency medical service delay (call-to hospital): 35 min. Door-in-door-out in the primary hospital: 85 min. Secondary transport (DODI): 26 min. Door-to-arterial puncture: 21 min. Puncture to recanalization: 24 min. Mothership with classical imaging strategy (admission to a thrombectomy centre with noninvasive imaging first): emergency medical service delay (call-to hospital): 35 min. Door-to-arterial puncture: 42 min. Arterial puncture to recanalization: 24 min. Mothership with direct transfer to angiography suite (admission to a thrombectomy centre with direct transfer to angiography suite, i.e. ST-elevation myocardial infarction -like strategy): emergency medical service delay (call-to hospital): 35 min. Door-to-arterial puncture: 18 min. Arterial puncture to recanalization: 24 min. Total ‘call-to recanalization’ time: 77 min.

Figure 2

Flat detector computed tomography images (left) with no signs of intracranial bleeding and no clear signs of developed ischaemia. Selective angiogram done immediately after flat detector computed tomography with the same equipment showing middle cerebral artery occlusion (middle) and reopening after thrombectomy (right).

Figure 3

Possible modes of early diagnostic approach to acute stroke to select patients for acute thrombectomy.

Figure 4

Typical case of basilar artery occlusion (left side). TICI 3 recanalization achieved using direct aspiration technique (right side).

Figure 5

Tandem lesion. Angiogram showing ruptured atherosclerotic plaque with large thrombus in the carotid bifurcation causing the occlusion of external carotid artery and near occlusion of proximal internal carotid artery (first left). Selective intracranial angiogram acquired after passing through the proximal internal carotid artery near occlusion is showing proximal middle cerebral artery occlusion (middle left). Intracranial recanalization was achieved first, using direct aspiration technique with a large bore sheath placed behind the proximal internal carotid artery lesion (middle right). Final result after implantation of the stent to proximal internal carotid artery (right).