Latest Advances in the Treatment of Acute Stroke

Abstract

Support: No funding was received in the publication of this article. About 85% of strokes are ischemic, and the most severe ischemic strokes are caused by large vessel occlusion due to either artery-to-artery embolism or cardiac embolism. Early treatment is essential to rescue potentially salvageable tissue. Until recently, the only proven treatment for acute ischemic stroke was intravenous thrombolysis with recombinant tissue-type plasminogen activator (tPA). However, since December 2014, several randomized controlled trials have demonstrated the efficacy and safety of mechanical endovascular thrombectomy. The clinical benefit of endovascular thrombectomy when performed within 6 hours after the onset of stroke symptoms is now well established. Recently, two clinical trials found that this time window could be extended in patients selected based on computed tomography (CT) perfusion imaging analyzed with RAPID software [iSchemaView, Inc., Menlo Park, CA, US]. The DAWN study found that in people who have relatively small ischemic cores and occlusion of either the intracranial internal carotid or the proximal middle cerebral artery, endovascular therapy at 6–24 hours post-stroke onset plus medical therapy produced better functional outcomes at 90 days compared with medical therapy alone. In DEFUSE-3, patients with large vessel strokes with favorable ischemic core to penumbra ratios, endovascular therapy at 6–16 hours post stroke onset, in addition to medical therapy, improved functional neurological outcome at 90 days, compared with medical therapy alone. In an expert interview, Jeffrey M Katz discusses these advances in stroke treatment.