Technology Insight: recanalization with drugs and devices during acute ischemic stroke

Abstract

Revascularization therapy is pivotal to saving ischemic brain from infarction. Two major randomized trials of intravenous thrombolytic therapy have established clear clinical benefit, especially for strokes caused by small-vessel occlusion. Ischemic stroke caused by large-vessel intracranial occlusion carries higher morbidity, however, and intravenous thrombolytics are less capable of opening these large vessels. This observation makes a case for delivering thrombolytics directly into the clot, or simply removing the clot mechanically. Intra-arterial thrombolytic drugs have been shown to be effective for treating middle cerebral artery occlusions in a major randomized trial. In the past 2 years, a family of mechanical thrombectomy catheters designed to remove rather than dissolve the offending clot has received FDA clearance. Such devices offer alternative therapy to patients who cannot receive thrombolytics, and can also be used in combination with thrombolytics to safely restore cerebral perfusion. Mechanical techniques have not been directly compared with intra-arterial thrombolytic strategies, but these devices might be superior to thrombolytics within vessels with particularly high clot burden, such as the carotid terminus and the basilar artery. Comprehensive stroke centers are currently available in major metropolitan areas to treat stroke via intra-arterial means, and are likely to become 'hubs' to 'spoke' hospitals that are credentialed as primary stroke centers. This design will allow any patient timely access to state-of-the-art stroke treatment tailored to their needs.

A modified suture technique produces consistent cerebral infarction in rats

“…Recently, recanalization with drugs during acute ischemic stroke have been shown to be clinically effective for treating ischemic stroke [24]. Thus, a reliable animal model of transient focal ischemia is becoming more important in order to study the pathophysiology of ischemic stroke and evaluate new therapeutic approaches.…”

A case of acute ischemic stroke: optimizing management with penumbra and vessel imaging

“…The technical efficacy and safety profile of the Merci ® Retriever device have been evaluated in prospective trials of patients with large-vessel stroke treated within 8 h. 11,12 These trials showed recanalization rates that ranged from 46% to 69%, depending on whether adjunctive therapies were used, and also that good neurologic outcomes were more frequent, and mortality was lower, in patients with successful recanalization. 13 Several ongoing trials comparing mechanical and medical reperfusion therapies will also evaluate whether multimodal MRI can identify those patients likely to benefit from each treatment, as well as those likely to be harmed. 14 …”

Workflow Optimization in Vertebrobasilar Occlusion

“…Intravenous and intra-arterial thrombolysis combined with mechanical thombectomy is a promising option, especially in patients with high clot burden and proximal vessel occlusion, as suggested by Smith [5]. Venker et al [6] examined this approach with the Solitaire stent device in the anterior circulation in 10 patients.…”

“…One fundamental prognostic factor is rapid recanalization by early percutaneous treatment [4]. Without treatment, the prognosis of VBO is almost always fatal, with mortality rates from 80% to 90% [5,6].…”