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Changing Management of Acute Ischaemic Stroke: the New Treatments and Emerging Role of Endovascular Therapy

  • Cerebrovascular Disorders (HP Adams, Section Editor)
  • Published:
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Opinion statement

Urgent reperfusion of the ischaemic brain is the aim of stroke treatment, and the last two decades have seen a rapid advancement in the medical and endovascular treatment of acute ischaemic stroke. Intravenous tissue plasminogen activator (tPA) was first introduced as a safe and effective thrombolytic agent followed by the introduction of newer thrombolytic agents as well as anticoagulant and antiplatelet agents, proposed as potentially safer drugs with more favourable interaction profiles. In addition to chemo-thrombolysis, other techniques including transcranial sonothrombolysis and microbubble cavitation have been introduced which are showing promising results, but await large-scale clinical trials. These developments in medical therapies which are undoubtedly of great importance due to their potential widespread and immediate availability are paralleled with gradual but steady improvements in endovascular recanalisation techniques which were initiated by the introduction of the MERCI (Mechanical Embolus Removal in Cerebral Ischemia) and Penumbra systems. The introduction of the Solitaire device was a significant achievement in reliable and safe endovascular recanalisation and was followed by further innovative stent retrievers. Initial trials failed to show a solid benefit in endovascular intervention compared with IV-tPA alone. These counterintuitive results did not last long, however, when a series of very well-designed randomised controlled trials, pioneered by MR-CLEAN, EXTEND-IA and ESCAPE, emerged, confirming the well-believed daily anecdotal evidence. There have now been seven positive trials of endovascular treatment for acute ischaemic stroke. Now that level I evidence regarding the superiority of endovascular recanalisation is abundantly available, the clinical challenge is how to select patients suitable for intervention and to familiarise and educate stroke care providers with this recent development in stroke care. It is important for the interventional services to be provided only in comprehensive stroke centres and endovascular interventions attempted by experienced well-trained operators, at this stage as an adjunct to the established medical treatment of IV-tPA, if there are no contraindications.

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Papers of particular interest, published recently have been highlighted as: • Of importance •• Of major importance

  1. Ferrell AS, Britz GW. Developments on the horizon in the treatment of neurovascular problems. Surg Neurol Int. 2013;4 Suppl 1:S31–7.

    PubMed  PubMed Central  Google Scholar 

  2. Blackham KA, Meyers PM, Abruzzo TA, et al. Endovascular therapy of acute ischemic stroke: report of the Standards of Practice Committee of the Society of NeuroInterventional Surgery. J Neuroint Surg. 2012;4(2):87–93.

    Article  CAS  Google Scholar 

  3. Gonzalez RG, Copen WA, Schaefer PW, et al. The Massachusetts General Hospital acute stroke imaging algorithm: an experience and evidence based approach. J Neuroint Surg. 2013;5 Suppl 1:i7–12.

    Article  Google Scholar 

  4. Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome—a meta-analysis. Stroke. 2007;38(967):973.

    Google Scholar 

  5. Meretoja A, Keshtkaran M, Saver JL, et al. Stroke thrombolysis: save a minute, save a day. Stroke J Cereb Circ. 2014;45(4):1053–8.

    Article  Google Scholar 

  6. Rha J-H, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke J Cereb Circ. 2007;38(3):967–73.

    Article  Google Scholar 

  7. Saqqur M, Uchino K, Demchuk AM, et al. Site of arterial occlusion identified by transcranial Doppler predicts the response to intravenous thrombolysis for stroke. Stroke J Cereb Circ. 2007;38(3):948–54.

    Article  Google Scholar 

  8. Eissa A, Krass I, Levi C, Sturm J, Ibrahim R, Bajorek B. Understanding the reasons behind the low utilisation of thrombolysis in stroke. Aust Med J. 2013;6(3):152.

    Article  Google Scholar 

  9. Asadi H, Yan B, Dowling R, Wong S, Mitchell P. Advances in medical revascularisation treatments in acute ischemic stroke. Thrombosis. 2014; 2014

  10. Barreto AD, Alexandrov AV. Adjunctive and alternative approaches to current reperfusion therapy. StrokeJ Cereb Circ. 2012;43(2):591–8.

    Article  Google Scholar 

  11. del Zoppo GJ, Poeck K, Pessin MS, et al. Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke. Ann Neurol. 1992;32(1):78–86.

    Article  PubMed  Google Scholar 

  12. Riedel CH, Zimmermann P, Jensen-Kondering U, Stingele R, Deuschl G, Jansen O. The importance of size: successful recanalization by intravenous thrombolysis in acute anterior stroke depends on thrombus length. Stroke J Cereb Circ. 2011;42(6):1775–7.

    Article  Google Scholar 

  13. Molina CA, Montaner J, Arenillas JF, Ribo M, Rubiera M, Alvarez-Sabín J. Differential pattern of tissue plasminogen activator-induced proximal middle cerebral artery recanalization among stroke subtypes. Stroke J Cereb Circ. 2004;35(2):486–90.

    Article  Google Scholar 

  14. Rubiera M, Alvarez-Sabín J, Ribo M, et al. Predictors of early arterial reocclusion after tissue plasminogen activator-induced recanalization in acute ischemic stroke. Stroke J cereb Circ. 2005;36(7):1452–6.

    Article  Google Scholar 

  15. Del Zoppo GJ, Saver JL, Jauch EC, Adams Jr HP. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke J Cereb Circ. 2009;40(8):2945–8.

    Article  Google Scholar 

  16. Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 Suppl):483S–512S.

    Article  CAS  PubMed  Google Scholar 

  17. Tissue plasminogen activator for acute ischemic stroke. New Engl J Med 1995; 333(24): 1581–7.

  18. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317–29.

    Article  CAS  PubMed  Google Scholar 

  19. Zinkstok SM, Roos YB. Early administration of aspirin in patients treated with alteplase for acute ischaemic stroke: a randomised controlled trial. Lancet. 2012;380(9843):731–7.

    Article  CAS  PubMed  Google Scholar 

  20. Sandercock P, Wardlaw JM, Lindley RI, et al. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet. 2012;379(9834):2352–63.

    Article  PubMed  Google Scholar 

  21. Ahmed N, Kellert L, Lees KR, Mikulik R, Tatlisumak T, Toni D. Results of intravenous thrombolysis within 4.5 to 6 hours and updated results within 3 to 4.5 hours of onset of acute ischemic stroke recorded in the Safe Implementation of Treatment in Stroke International Stroke Thrombolysis Register (SITS-ISTR): an observational study. JAMA Neurol. 2013;70(7):837–44.

    Article  PubMed  Google Scholar 

  22. Alvarez-Fernandez JA. Ultrasound-enhanced systemic thrombolysis. An effective and underutilized treatment for acute ischemic stroke. Med intensiva Soc Esp Med Intensiva y Unidades Coronarias. 2011;35(2):134–5.

    Article  CAS  Google Scholar 

  23. Alexandrov AV, Molina CA, Grotta JC, et al. Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke. N Engl J Med. 2004;351(21):2170–8.

    Article  CAS  PubMed  Google Scholar 

  24. Siebler M, Hennerici MG, Schneider D, et al. Safety of Tirofiban in acute Ischemic Stroke: the SaTIS trial. Stroke J Cereb Circ. 2011;42(9):2388–92.

    Article  CAS  Google Scholar 

  25. Cerevast. Phase 3, Randomized, Placebo-Controlled, Double-Blinded Trial of the Combined Lysis of Thrombus With Ultrasound and Systemic Tissue Plasminogen Activator (tPA) for Emergent Revascularization in Acute Ischemic Stroke (CLOTBUST-ER). In: ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US).2014 - [cited 13 December 2014]. Available from: http://clinicaltrials.gov/show/NCT01098981.

  26. Molina CA, Barreto AD, Tsivgoulis G, et al. Transcranial ultrasound in clinical sonothrombolysis (TUCSON) trial. Ann Neurol. 2009;66(1):28–38.

    Article  CAS  PubMed  Google Scholar 

  27. Molina CA, Ribo M, Rubiera M, et al. Microbubble administration accelerates clot lysis during continuous 2-MHz ultrasound monitoring in stroke patients treated with intravenous tissue plasminogen activator. Stroke J Cereb Circ. 2006;37(2):425–9.

    Article  CAS  Google Scholar 

  28. Smith WS, Sung G, Starkman S, et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke J Cereb Circ. 2005;36(7):1432–8. One of the early mechanical thrombectomy trials.

    Article  Google Scholar 

  29. Mikulik R, Dufek M, Goldemund D, Reif M. A pilot study on systemic thrombolysis followed by low molecular weight heparin in ischemic stroke. Eur J Neurol Off J Eur Fed Neurol Soc. 2006;13(10):1106–11.

    CAS  Google Scholar 

  30. Zinkstok SM, Vermeulen M, Stam J, de Haan RJ, Roos YB. A randomised controlled trial of antiplatelet therapy in combination with Rt-PA thrombolysis in ischemic stroke: rationale and design of the ARTIS-Trial. Trials. 2010;11:51.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. del Zoppo GJ, Higashida RT, Furlan AJ, Pessin MS, Rowley HA, Gent M. PROACT: a phase II randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke. PROACT Investigators. Prolyse in Acute Cerebral Thromboembolism. Stroke J Cereb Circ. 1998;29(1):4–11. One of the pioneer studies into intra-arterial thrombolysis in the setting of acute ischemic stroke.

    Article  Google Scholar 

  32. Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA J Am Med Assoc. 1999;282(21):2003–11.

    Article  CAS  Google Scholar 

  33. Yepes M, Roussel BD, Ali C, Vivien D. Tissue-type plasminogen activator in the ischemic brain: more than a thrombolytic. Trends Neurosci. 2009;32(1):48–55.

    Article  CAS  PubMed  Google Scholar 

  34. Molina CA, Saver JL. Extending reperfusion therapy for acute ischemic stroke: emerging pharmacological, mechanical, and imaging strategies. Stroke J Cereb Circ. 2005;36(10):2311–20.

    Article  Google Scholar 

  35. Haley Jr EC, Thompson JL, Grotta JC, et al. Phase IIB/III trial of tenecteplase in acute ischemic stroke: results of a prematurely terminated randomized clinical trial. Stroke J Cereb Circ. 2010;41(4):707–11.

    Article  CAS  Google Scholar 

  36. Haley Jr EC, Lyden PD, Johnston KC, Hemmen TM. A pilot dose-escalation safety study of tenecteplase in acute ischemic stroke. Stroke J Cereb Circ. 2005;36(3):607–12.

    Article  CAS  Google Scholar 

  37. Parsons M, Spratt N, Bivard A, et al. A randomized trial of tenecteplase versus alteplase for acute ischemic stroke. N Engl J Med. 2012;366(12):1099–107.

    Article  CAS  PubMed  Google Scholar 

  38. Logallo N, Kvistad CE, Nacu A, et al. The Norwegian tenecteplase stroke trial (NOR-TEST): randomised controlled trial of tenecteplase vs. alteplase in acute ischaemic stroke. BMC neurology. 2014;14(1):106.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Hacke W, Albers G, Al-Rawi Y, et al. The Desmoteplase in Acute Ischemic Stroke Trial (DIAS): a phase II MRI-based 9-hour window acute stroke thrombolysis trial with intravenous desmoteplase. Stroke J Cereb Circ. 2005;36(1):66–73.

    Article  CAS  Google Scholar 

  40. Furlan AJ, Eyding D, Albers GW, et al. Dose Escalation of Desmoteplase for Acute Ischemic Stroke (DEDAS): evidence of safety and efficacy 3 to 9 hours after stroke onset. Stroke J Cereb Circ. 2006;37(5):1227–31.

    Article  CAS  Google Scholar 

  41. Hacke W, Furlan AJ, Al-Rawi Y, et al. Intravenous desmoteplase in patients with acute ischaemic stroke selected by MRI perfusion-diffusion weighted imaging or perfusion CT (DIAS-2): a prospective, randomised, double-blind, placebo-controlled study. Lancet Neurol. 2009;8(2):141–50.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Kummer R, Albers GW, Mori E. The desmoteplase in acute ischemic stroke (DIAS) clinical trial program. Int J Stroke. 2012;7(7):589–96.

    Article  Google Scholar 

  43. Sherman DG, Atkinson RP, Chippendale T, et al. Intravenous ancrod for treatment of acute ischemic stroke: the STAT study: a randomized controlled trial. Stroke Treatment with Ancrod Trial. JAMA J Am Med Assoc. 2000;283(18):2395–403.

    Article  CAS  Google Scholar 

  44. Levy DE, del Zoppo GJ, Demaerschalk BM, et al. Ancrod in acute ischemic stroke: results of 500 subjects beginning treatment within 6 hours of stroke onset in the ancrod stroke program. Stroke J Cereb Circ. 2009;40(12):3796–803.

    Article  Google Scholar 

  45. Hennerici MG, Kay R, Bogousslavsky J, Lenzi GL, Verstraete M, Orgogozo JM. Intravenous ancrod for acute ischaemic stroke in the European Stroke Treatment with Ancrod Trial: a randomised controlled trial. Lancet. 2006;368(9550):1871–8.

    Article  CAS  PubMed  Google Scholar 

  46. Jang IK, Brown DF, Giugliano RP, et al. A multicenter, randomized study of argatroban versus heparin as adjunct to tissue plasminogen activator (TPA) in acute myocardial infarction: myocardial infarction with novastan and TPA (MINT) study. J Am Coll Cardiol. 1999;33(7):1879–85.

    Article  CAS  PubMed  Google Scholar 

  47. Kawai H, Umemura K, Nakashima M. Effect of argatroban on microthrombi formation and brain damage in the rat middle cerebral artery thrombosis model. Jpn J Pharmacol. 1995;69(2):143–8.

    Article  CAS  PubMed  Google Scholar 

  48. Morris DC, Zhang L, Zhang ZG, et al. Extension of the therapeutic window for recombinant tissue plasminogen activator with argatroban in a rat model of embolic stroke. Stroke J Cereb Circ. 2001;32(11):2635–40.

    Article  CAS  Google Scholar 

  49. LaMonte MP, Nash ML, Wang DZ, et al. Argatroban anticoagulation in patients with acute ischemic stroke (ARGIS-1): a randomized, placebo-controlled safety study. Stroke J Cereb Circ. 2004;35(7):1677–82.

    Article  CAS  Google Scholar 

  50. Sugg RM, Pary JK, Uchino K, et al. Argatroban tPA stroke study: study design and results in the first treated cohort. Arch Neurol. 2006;63(8):1057–62.

    Article  PubMed  Google Scholar 

  51. Barreto AD, Alexandrov AV, Lyden P, et al. The argatroban and tissue-type plasminogen activator stroke study: final results of a pilot safety study. Stroke J Cereb Circ. 2012;43(3):770–5.

    Article  CAS  Google Scholar 

  52. Barreto AD. Randomized Controlled Trial of Argatroban With tPA for Acute Stroke (ARTSS-2). In: ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2011 - [cited 13 December 2014]. Available from: https://clinicaltrials.gov/show/NCT01464788.

  53. Javedani PP, Horowitz BZ, Clark WM, Lutsep HL. Dabigatran etexilate: management in acute ischemic stroke. Am J Crit Care. 2013;22(2):169–76.

    Article  PubMed  Google Scholar 

  54. Lee JY, Markland FS, Lucchesi BR. Hirudin and S18886 maintain luminal patency after thrombolysis with alfimeprase. J Cardiovasc Pharmacol. 2013;61(2):152–9.

    Article  CAS  PubMed  Google Scholar 

  55. Boudreau DM, Guzauskas GF, Chen E, et al. Cost-effectiveness of recombinant tissue-type plasminogen activator within 3 hours of acute ischemic stroke current evidence. Stroke. 2014;45(10):3032–9.

    Article  PubMed  Google Scholar 

  56. Eisenberg PR, Sobel BE, Jaffe AS. Activation of prothrombin accompanying thrombolysis with recombinant tissue-type plasminogen activator. J Am Coll Cardiol. 1992;19(5):1065–9.

    Article  CAS  PubMed  Google Scholar 

  57. Pereira H. Reperfusion therapy for acute myocardial infarction with fibrinolytic therapy or combination reduced fibrinolytic therapy and platelet glycoprotein IIb/IIIa inhibition: the GUSTO V randomised trial. Revista portuguesa de cardiologia : orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese J Cardiol Off J Portuguese Soc Cardiol 2001;20(6):687–8.

  58. Ohman EM, Kleiman NS, Gacioch G, et al. Combined accelerated tissue-plasminogen activator and platelet glycoprotein IIb/IIIa integrin receptor blockade with Integrilin in acute myocardial infarction. Results of a randomized, placebo-controlled, dose-ranging trial. IMPACT-AMI Investigators. Circulation. 1997;95(4):846–54.

    Article  CAS  PubMed  Google Scholar 

  59. Adams Jr HP, Effron MB, Torner J, et al. Emergency administration of abciximab for treatment of patients with acute ischemic stroke: results of an international phase III trial: Abciximab in Emergency Treatment of Stroke Trial (AbESTT-II). Stroke J Cereb Circ. 2008;39(1):87–99.

    Article  CAS  Google Scholar 

  60. Torgano G, Zecca B, Monzani V, et al. Effect of intravenous tirofiban and aspirin in reducing short-term and long-term neurologic deficit in patients with ischemic stroke: a double-blind randomized trial. Cerebrovasc Dis. 2010;29(3):275–81.

    Article  CAS  PubMed  Google Scholar 

  61. Pancioli AM, Adeoye O, Schmit PA, et al. Combined approach to lysis utilizing eptifibatide and recombinant tissue plasminogen activator in acute ischemic stroke-enhanced regimen stroke trial. Stroke J Cereb Circ. 2013;44(9):2381–7.

    Article  Google Scholar 

  62. Ciccone A, Motto C, Abraha I, Cozzolino F, Santilli I. Glycoprotein IIb-IIIa inhibitors for acute ischaemic stroke. Cochrane Database Syst Rev 2014;3.

  63. Sandercock PA, Counsell C, Gubitz GJ, Tseng MC. Antiplatelet therapy for acute ischaemic stroke. The Cochrane Library 2008.

  64. Mokin M, Khalessi AA, Mocco J, et al. Endovascular treatment of acute ischemic stroke: the end or just the beginning? Neurosurg Focus. 2014;36(1):E5.

    Article  PubMed  Google Scholar 

  65. The Interventional Management of Stroke (IMS) II Study. Stroke J Cereb Circ 2007; 38(7): 2127–35.

  66. Asadi H, Dowling R, Yan B, Wong S, Mitchell P. Advances in endovascular treatment of acute ischemic stroke. Int Med J. 2014.

  67. Smith WS, Sung G, Saver J, et al. Mechanical thrombectomy for acute ischemic stroke: final results of the multi MERCI trial. Stroke J Cereb circ. 2008;39(4):1205–12.

    Article  Google Scholar 

  68. The penumbra pivotal stroke trial: safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. Stroke J Cereb Circ 2009; 40(8): 2761–8.

  69. Saver JL, Jahan R, Levy EI, et al. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet. 2012;380(9849):1241–9.

    Article  PubMed  Google Scholar 

  70. Nogueira RG, Liebeskind DS, Sung G, Duckwiler G, Smith WS. Predictors of good clinical outcomes, mortality, and successful revascularization in patients with acute ischemic stroke undergoing thrombectomy: pooled analysis of the Mechanical Embolus Removal in Cerebral Ischemia (MERCI) and multi MERCI trials. Stroke J Cereb Circ. 2009;40(12):3777–83.

    Article  Google Scholar 

  71. Investigators PPST. The penumbra pivotal stroke trial safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. Stroke. 2009;40(8):2761–8.

    Article  Google Scholar 

  72. Levy EI, Mehta R, Gupta R, et al. Self-expanding stents for recanalization of acute cerebrovascular occlusions. AJNR Am J Neuroradiol. 2007;28(5):816–22.

    CAS  PubMed  Google Scholar 

  73. Nogueira RG, Schwamm LH, Buonanno FS, et al. Low-pressure balloon angioplasty with adjuvant pharmacological therapy in patients with acute ischemic stroke caused by intracranial arterial occlusions. Neuroradiology. 2008;50(4):331–40.

    Article  PubMed  Google Scholar 

  74. Fiorella DJ, Levy EI, Turk AS, et al. Target lesion revascularization after wingspan: assessment of safety and durability. Stroke J Cereb Circ. 2009;40(1):106–10.

    Article  Google Scholar 

  75. Levy EI, Rahman M, Khalessi AA, et al. Midterm clinical and angiographic follow-up for the first Food and Drug Administration-approved prospective, single-arm trial of primary stenting for stroke: SARIS (Stent-Assisted Recanalization for Acute Ischemic Stroke). Neurosurgery. 2011;69(4):915–20. discussion 20.

    Article  PubMed  Google Scholar 

  76. Levy EI, Siddiqui AH, Crumlish A, et al. First Food and Drug Administration-approved prospective trial of primary intracranial stenting for acute stroke: SARIS (stent-assisted recanalization in acute ischemic stroke). Stroke J Cereb Circ. 2009;40(11):3552–6.

    Article  Google Scholar 

  77. Fitzsimmons B-F, Becske T, Nelson P. Rapid stent-supported revascularization in acute ischemic stroke. Am J Neuroradiol. 2006;27(5):1132–4.

    PubMed  Google Scholar 

  78. Fulkerson J, Ferrera DA, Cragg A. Acute stroke revascularization/recanalization systems processes and products thereby. Google Patents; 2009

  79. Saver JL, Jahan R, Levy EI, et al. SOLITAIRE with the intention for thrombectomy (SWIFT) trial: design of a randomized, controlled, multicenter study comparing the SOLITAIRE Flow Restoration device and the MERCI Retriever in acute ischaemic stroke. Int J stroke Off J Int Stroke Soc. 2012.

  80. Nogueira RG, Lutsep HL, Gupta R, et al. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet. 2012;380(9849):1231–40.

    Article  PubMed  PubMed Central  Google Scholar 

  81. Broderick JP, Palesch YY, Demchuk AM, et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med. 2013;368(10):893–903.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  82. Demchuk A, Investigators II. IMS III: comparison of outcomes between IV and IV/IA treatment in baseline CTA confirmed ICA, M1, M2 and basilar occlusions. Int Stroke Conference; 2013; 2013

  83. Ciccone A, Valvassori L, Nichelatti M, et al. Endovascular treatment for acute ischemic stroke. N Engl J Med. 2013;368(10):904–13.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  84. Kidwell CS, Jahan R, Gornbein J, et al. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med. 2013;368(10):914–23.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  85. Yoo AJ, Verduzco LA, Schaefer PW, Hirsch JA, Rabinov JD, Gonzalez RG. MRI-based selection for intra-arterial stroke therapy: value of pretreatment diffusion-weighted imaging lesion volume in selecting patients with acute stroke who will benefit from early recanalization. Stroke J Cereb Circ. 2009;40(6):2046–54.

    Article  Google Scholar 

  86. Keller DM. ‘Mr Clean’ Polishes Stroke Outcome With Endovascular Therapy. Medscape Medical News: 9th World Stroke Congress (WSC);2014.

  87. Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. New Engl J Med. 2015;372(1):11–20. This is was the first randomised control trial into the efficacy of endovascular treatment for acute ischemic stroke, performed by a Dutch group as a large well-designed multicentric study, with the preliminary result announced during the international conference of stroke, breaking the equipoise and forcing several other trials to be on hold.

    Article  PubMed  Google Scholar 

  88. National Stroke Research Institute A. Extending the Time for Thrombolysis in Emergency Neurological Deficits-Intra-Arterial (EXTEND-IA).

  89. Campbell BCV, Yassi N, Ma H, et al. Imaging selection in ischemic stroke: feasibility of automated CT-perfusion analysis. Int J Stroke. 2015;10(1):51–4.

    Article  PubMed  Google Scholar 

  90. Straka M, Albers GW, Bammer R. Real-time diffusion-perfusion mismatch analysis in acute stroke. J Magn Reson Imaging. 2010;32(5):1024–37.

    Article  PubMed  PubMed Central  Google Scholar 

  91. Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. New Engl J Med. 2015;372(11):1009––18. This is a randomised control trial into comparing endovascular thrombectomy combined with IV-tPA with IV-tPA alone with emphasis on patient selection based on CT perfusion and advanced penumbral imaging.

    Article  PubMed  Google Scholar 

  92. Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. New Engl J Med. 2015;372(11):1019–30. This is a randomised control trial into efficacy of endovascular thrombectomy compared with IV-tPA in patients presented not later than 12 h post onset with emphasis on ASPECT score at the time of presentation and the situations of the collaterals based on a three-phase CTA.

    Article  CAS  PubMed  Google Scholar 

  93. Molina CA, Chamorro A, Rovira À, et al. REVASCAT: a randomized trial of revascularization with SOLITAIRE FR® device vs. best medical therapy in the treatment of acute stroke due to anterior circulation large vessel occlusion presenting within eight‐hours of symptom onset. Int J Stroke 2013.

  94. Smith WS, Yan B. REVASCAT trial: further advancement in endovascular stroke therapy. Stroke. 2015;46(10):3012–3.

    Article  PubMed  Google Scholar 

  95. Khatri P, Hacke W, Fiehler J, et al. State of acute endovascular therapy report from the 12th thrombolysis, thrombectomy, and acute stroke therapy conference. Stroke. 2015;46(6):1727–34.

    Article  PubMed  Google Scholar 

  96. Bracard S, Guillemin F, Ducrocq X. THRACE study: intermediate analysis results. Int J Stroke; 2015: Wiley-Blackwell, 111 River St, Hoboken 07030-5774, NJ, USA; 2015. p. 31

  97. Baek J, Yoon W, Kim S, et al. Acute basilar artery occlusion: outcome of mechanical thrombectomy with solitaire stent within 8 hours of stroke onset. Am J Neuroradiol. 2014;35(5):989–93.

    Article  CAS  PubMed  Google Scholar 

  98. Levy EI, Firlik AD, Wisniewski S, et al. Factors affecting survival rates for acute vertebrobasilar artery occlusions treated with intra-arterial thrombolytic therapy: a meta-analytical approach. Neurosurgery. 1999;45(3):539–45. discussion 45–8.

    Article  CAS  PubMed  Google Scholar 

  99. Schonewille WJ, Wijman CA, Michel P, et al. Treatment and outcomes of acute basilar artery occlusion in the Basilar Artery International Cooperation Study (BASICS): a prospective registry study. Lancet Neurol. 2009;8(8):724–30.

    Article  PubMed  Google Scholar 

  100. Broussalis E, Hitzl W, McCoy M, Trinka E, Killer M. Comparison of endovascular treatment versus conservative medical treatment in patients with acute basilar artery occlusion. Vasc Endovasc Surg. 2013;1538574413488458.

  101. Asadi H, Dowling R, Yan B, Mitchell P. Machine learning for outcome prediction of acute ischemic stroke post intra-arterial therapy. PLoS One. 2014;2:e88225. The first study published on the role of machine learning and artificial intelligence in prognostication and predication of the patients’ outcome in acute ischemic stroke.

    Article  Google Scholar 

  102. Grech R, Galvin PL, Power S, et al. Outcome prediction in acute stroke patients considered for endovascular treatment: a novel tool. Interv Neuroradiol. 2014;20(3):312–24.

    PubMed  Google Scholar 

  103. MacIsaac RL, Khatri P, Bendszus M, et al. A collaborative sequential meta‐analysis of individual patient data from randomized trials of endovascular therapy and tPA vs. tPA alone for acute ischemic stroke: ThRombEctomy And tPA (TREAT) analysis: statistical analysis plan for a sequential meta‐analysis performed within the VISTA‐Endovascular collaboration. Int J Stroke. 2015;10(A100):136–44.

    Article  PubMed  Google Scholar 

  104. Majid A. Neuroprotection in stroke: past, present, and future. ISRN Neurol. 2014;2014.

  105. Choi K-E, Hall CL, Sun J-M, et al. A novel stroke therapy of pharmacologically induced hypothermia after focal cerebral ischemia in mice. FASEB J. 2012;26(7):2799–810.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  106. Li Y-S, Shemmer B, Stone E, Nardi MA, Jonas S, Quartermain D. Neuroprotection by inhaled nitric oxide in a murine stroke model is concentration and duration dependent. Brain Res. 2013;1507:134–45.

    Article  CAS  PubMed  Google Scholar 

  107. Sutherland BA, Minnerup J, Balami JS, Arba F, Buchan AM, Kleinschnitz C. Neuroprotection for ischaemic stroke: translation from the bench to the bedside. Int J Stroke. 2012;7(5):407–18.

    Article  PubMed  Google Scholar 

  108. Tymianski M. Novel approaches to neuroprotection trials in acute ischemic stroke. Stroke. 2013;44(10):2942–50. Important breakthrough in the role of neuroprotective agents in acute ischemic stroke in animal models.

    Article  PubMed  Google Scholar 

  109. Campbell BC, Donnan GA, Lees KR, et al. Endovascular stent thrombectomy: the new standard of care for large vessel ischaemic stroke. Lancet Neurol. 2015;14(8):846–54.

    Article  PubMed  Google Scholar 

  110. Walter S, Kostpopoulos P, Haass A, et al. Bringing the hospital to the patient: first treatment of stroke patients at the emergency site. PLoS ONE. 2010;5(10):e13758.

    Article  PubMed  PubMed Central  Google Scholar 

  111. Perez de la Ossa N, Carrera D, Gorchs M, et al. Design and validation of a prehospital stroke scale to predict large arterial occlusion: the rapid arterial occlusion evaluation scale. Stroke. 2014;45(1):87–91.

    Article  PubMed  Google Scholar 

  112. Ebinger M, Fiebach JB, Audebert HJ. Mobile computed tomography: prehospital diagnosis and treatment of stroke. Curr Opin Neurol. 2015;28(1):4–9.

    Article  PubMed  Google Scholar 

  113. Cerejo R, John S, Buletko AB, et al. A mobile stroke treatment unit for field triage of patients for intraarterial revascularization therapy. J Neuroimaging. 2015;25(6):940–5.

    Article  PubMed  Google Scholar 

  114. Wahlgren N, Moreira T, Michel P, et al. Mechanical thrombectomy in acute ischemic stroke: consensus statement by ESO-Karolinska Stroke Update 2014/2015, supported by ESO, ESMINT. ESNR and EAN Int J Stroke. 2016;11(1):134–47.

    Article  PubMed  Google Scholar 

  115. Powers WJ, Derdeyn CP, Biller J, et al. American Heart Association Stroke Council: 2015 AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015.

  116. Coutts SB, Wein TH, Lindsay MP, et al. Canadian Stroke Best Practice Recommendations: secondary prevention of stroke guidelines, update 2014. Int J Stroke. 2015;10(3):282–91.

    Article  PubMed  Google Scholar 

  117. Schwamm LH, Pancioli A, Acker 3rd JE, et al. Recommendations for the establishment of stroke systems of care: recommendations from the American Stroke Association’s Task Force on the Development of Stroke Systems. Circulation. 2005;111(8):1078–91.

    Article  PubMed  Google Scholar 

  118. Ding D. Endovascular mechanical thrombectomy for acute ischemic stroke: a new standard of care. J Stroke. 2015;17:123–6.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgments

A special thank is due to Dr. Myrna Rosenfeld for taking the time to review this manuscript.

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Authors and Affiliations

  1. Neuroradiology and Neurointerventional Service, Department of Radiology, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin, Ireland

    Hamed Asadi MD, PhD, FRANZCR & John Thornton MB, BCh, BAO, FRCR, FFR, FRCSI

  2. School of Medicine, Faculty of Health, Deakin University, Pigdons Road, Waurn Ponds, VIC, 3216, Australia

    Hamed Asadi MD, PhD, FRANZCR

  3. Interventional Radiology Service, Department of Radiology, Beaumont Hospital, Beaumont Rd, Beaumont, Dublin, Ireland

    Hamed Asadi MD, PhD, FRANZCR

  4. Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland and Beaumont Hospital, Beaumont Rd, Beaumont, Dublin, Ireland

    David Williams MB, BAO, BCh, PhD, FRCPI, FRCPE

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  1. Hamed Asadi MD, PhD, FRANZCR
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  2. David Williams MB, BAO, BCh, PhD, FRCPI, FRCPE
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  3. John Thornton MB, BCh, BAO, FRCR, FFR, FRCSI
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Correspondence to Hamed Asadi MD, PhD, FRANZCR.

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Conflict of Interest

Hamed Asadi declares no conflict of interest.

David Williams has received advisory board fees from Boehringer Ingelheim, Daiichi Sankyo, Bayer and Bristol-Myers Squibb, along with payment for manuscript preparation from Boehringer Ingelheim. Dr. Williams is also a local co-investigator of ARISE (Analysis of Revascularisation in Ischemic Stroke with EmboTrap®) sponsored by Neuravi Ltd.

John Thornton has received advisory board fees from Neuravi, Galway, Ireland.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Cerebrovascular Disorders

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Asadi, H., Williams, D. & Thornton, J. Changing Management of Acute Ischaemic Stroke: the New Treatments and Emerging Role of Endovascular Therapy. Curr Treat Options Neurol 18, 20 (2016). https://doi.org/10.1007/s11940-016-0403-8

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