Evolving Treatments for Acute Ischemic Stroke

Abstract

Abstract:The purpose of this article is to review advances in stroke treatment in the hyperacute period. With recent evolutions of technology in the fields of imaging, thrombectomy devices, and emergency room workflow management, as well as improvement in statistical methods and study design, there have been ground breaking changes in the treatment of acute ischemic stroke. We describe how stroke presents as a clinical syndrome and how imaging as the most important biomarker will help differentiate between stroke subtypes and treatment eligibility. The evolution of hyperacute treatment has led to the current standard of care: intravenous thrombolysis with tissue-type plasminogen activator and endovascular treatment for proximal vessel occlusion in the anterior cerebral circulation. All patients with acute ischemic stroke are in need of hyperacute secondary prevention because the risk of recurrence is highest closest to the index event. The dominant themes of modern stroke care are the use of neurovascular imaging and speed of diagnosis and treatment. (Circ Res.

Towards Improved Translational Stroke Research

“…12 Failure of translation of over a thousand molecules that were proven to be effective in rodent or small mammal ischemia-reperfusion models may in large part be because of the fact that, in the recent past, human ischemic stroke was a permanent focal ischemia model and not a transient focal ischemic model as believed. 2 A fundamental principle of the human endovascular ischemic stroke trials was the identification of a target vessel occlusion and a tissue window for patient selection.…”

Advances in Thrombosis and Hemostasis

“…Hill et al 9 highlight the central role of brain imaging in defining management of acute ischemic stroke. Although intravenous thrombolytic therapy produces a clear benefit for patients presenting within 4.5 hours of onset of stroke symptoms, the introduction of thrombus extraction devices has provided the most dramatic advance.…”

2016 Scientific Sessions Sol Sherry Distinguished Lecturer in Thrombosis

“…In spite of much effort, only one drug has been FDA-approved for treating acute ischemic stroke in the past two decades, namely tissue plasminogen activator ( tPA ). 1–6 Extensive trial data indicate that the standard of care for all eligible patients is intravenous tPA within 4.5 h of stroke symptom onset. Neuroimaging and various other criteria are critical for selection of tPA-eligible patients.…”

“…Recent trial data indicate that endovascular reperfusion therapy can improve outcomes for some patients, with or without tPA therapy. 1–5 Success of mechanical neurothrombectomy employing newer devices requires excellent neuroimaging and considerations of multiple patient parameters. Ongoing research will hopefully enable more extensive utilization of endovascular procedures for acute ischemic stroke, though this is not the topic for this review.…”

“…12–14 Yet only tPA has achieved FDA approval. 1–6 Against this background of failed compounds, activated protein C ( APC ) presents a truly novel type of neuroprotective agent as summarized in this review. For a more detailed review of the extensive in vitro and preclinical data for APC’s neuroprotective actions, the reader is referred to the review in reference.…”