Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
Current Cardiology Reports
Published in: Current Cardiology Reports 4/2013

01-04-2013 | Peripheral Vascular Disease (M Shishehbor, Section Editor)

Management of Acute Ischemic Stroke

Author: Alex Abou-Chebl

Published in: Current Cardiology Reports | Issue 4/2013

Login to get access

Abstract

Acute stroke affects about 800,000 patients annually in the US and is the leading cause of disability. It is a complex condition with multiple causes and requires comprehensive but rapid evaluation by stroke specialists working in institutions with well-organized stroke systems of care. Acute stroke treatment is focused on early revascularization with intravenous tPA for those with strokes under 3 hours duration or intra-arterial therapy for most others and those who cannot receive tPA. The latter is evolving rapidly with the advent of stent-retriever embolectomy devices that are poised to revolutionize stroke treatment. Recanalization is associated with neurological recovery in 33–50 % of patients. This also means that many patients may have devastating and life-threatening brain injury, which highlights the need for comprehensive care for the prevention and treatment of medical complications, management of cerebral edema and intracerebral hemorrhage.
Literature
1.
Roger VL, Go AS, Lloyd-Jones DM, et al. Executive summary: heart disease and stroke statistics–2012 update: a report from the American Heart Association. Circulation. 2012;125:188–97.PubMedCrossRef
2.
Sacco RL, Benjamin EJ, Broderick JP, et al. American Heart Association Prevention Conference. IV. Prevention and Rehabilitation of Stroke. Risk factors. Stroke. 1997;28:1507–17.PubMedCrossRef
3.
Marler JR, Tilley BC, Lu M, et al. Early stroke treatment associated with better outcome: the NINDS rt-PA stroke study. Neurology. 2000;55:1649–55.PubMedCrossRef
4.
Hacke W, Donnan G, Fieschi C, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004;363:768–74.PubMedCrossRef
5.
Demaerschalk BM, Yip TR. Economic benefit of increasing utilization of intravenous tissue plasminogen activator for acute ischemic stroke in the United States. Stroke. 2005;36:2500–3.PubMedCrossRef
6.
Suzuki S, Saver JL, Scott P, et al. Access to intra-arterial therapies for acute ischemic stroke: an analysis of the US population. AJNR Am J Neuroradiol. 2004;25:1802–6.PubMed
7.
Cloft HJ, Rabinstein A, Lanzino G, Kallmes DF. Intra-arterial stroke therapy: an assessment of demand and available work force. AJNR Am J Neuroradiol. 2009;30:453–8.PubMedCrossRef
8.
Sacco RL, Boden-Albala B, Gan R, et al. Stroke incidence among white, black, and Hispanic residents of an urban community: the Northern Manhattan Stroke Study. Am J Epidemiol. 1998;147:259–68.PubMedCrossRef
9.
Caplan LR, Hennerici M. Impaired clearance of emboli (washout) is an important link between hypoperfusion, embolism, and ischemic stroke. Arch Neurol. 1998;55:1475–82.PubMedCrossRef
10.
Adams HP, Jr., del ZG, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007;38:1655-711.
11.
Adams RJ, Albers G, Alberts MJ, et al. Update to the AHA/ASA recommendations for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke. 2008;39:1647–52.PubMedCrossRef
12.
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. 1999;282:2003–11.PubMedCrossRef
13.
Morgenstern LB, Hemphill III JC, Anderson C, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010;41:2108–29.PubMedCrossRef
14.
Bederson JB, Connolly Jr ES, Batjer HH, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 2009;40:994–1025.PubMedCrossRef
15.
Johnson ER, McKenzie SW, Sievers A. Aspiration pneumonia in stroke. Arch Phys Med Rehabil. 1993;74:973–6.PubMed
16.
Teasell RW, McRae M, Marchuk Y, Finestone HM. Pneumonia associated with aspiration following stroke. Arch Phys Med Rehabil. 1996;77:707–9.PubMedCrossRef
17.
Lin K, Do KG, Ong P, et al. Perfusion CT improves diagnostic accuracy for hyperacute ischemic stroke in the 3-hour window: study of 100 patients with diffusion MRI confirmation. Cerebrovasc Dis. 2009;28:72–9.PubMedCrossRef
18.
•• Lansberg MG, Straka M, Kemp S, et al. MRI profile and response to endovascular reperfusion after stroke (DEFUSE 2): a prospective cohort study. Lancet Neurol. 2012;11:860-7. The first prospective study to show that patients with ischemic penumbra who are treated with IAT fair much better than those without a penumbra.
19.
• Abou-Chebl A. Endovascular treatment of acute ischemic stroke may be safely performed with no time window limit in appropriately selected patients. Stroke 2010;41:1996-2000. The first study to compare patients treated beyond 6 hours with those treated under 6 hours and to show the same good outcomes if patients are selected with perfusion imaging, dispelling the myth of an absolute time-window for stroke treatment.
20.
Duke RJ, Bloch RF, Turpie AG, Trebilcock R, Bayer N. Intravenous heparin for the prevention of stroke progression in acute partial stable stroke. Ann Intern Med. 1986;105:825–8.PubMed
21.
CAST: randomised placebo-controlled trial of early aspirin use in 20,000 patients with acute ischaemic stroke. CAST (Chinese Acute Stroke Trial) Collaborative Group. Lancet 1997;349:1641-49.
22.
The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group. Lancet 1997;349:1569-81.
23.
Abou-Chebl A, Vora N, Yadav JS. Safety of angioplasty and stenting without thrombolysis for the treatment of early ischemic stroke. J Neuroimaging. 2009;19:139–43.PubMedCrossRef
24.
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. 2008;39:87–99.PubMedCrossRef
25.
Abou-Chebl A, Bajzer CT, Krieger DW, Furlan AJ, Yadav JS. Multimodal therapy for the treatment of severe ischemic stroke combining GPIIb/IIIa antagonists and angioplasty after failure of thrombolysis. Stroke. 2005;36:2286–8.PubMedCrossRef
26.
Qureshi AI, Harris-Lane P, Kirmani JF, et al. Intra-arterial reteplase and intravenous abciximab in patients with acute ischemic stroke: an open-label, dose-ranging, phase I study. Neurosurgery. 2006;59:789–96.PubMedCrossRef
27.
Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med. 1995;333:1581-7.
28.
Albers GW, Clark WM, Madden KP, Hamilton SA. ATLANTIS trial: results for patients treated within 3 hours of stroke onset. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke. Stroke. 2002;33:493–5.PubMedCrossRef
29.
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;359:1317–29.PubMedCrossRef
30.
Wolpert SM, Bruckmann H, Greenlee R, Wechsler L, Pessin MS, del Zoppo GJ. Neuroradiologic evaluation of patients with acute stroke treated with recombinant tissue plasminogen activator. The rt-PA Acute Stroke Study Group. AJNR Am J Neuroradiol. 1993;14:3–13.PubMed
31.
Katzan IL, Hammer MD, Furlan AJ, Hixson ED, Nadzam DM. Quality improvement and tissue-type plasminogen activator for acute ischemic stroke: a Cleveland update. Stroke. 2003;34:799–800.PubMedCrossRef
32.
Alberts MJ, Hademenos G, Latchaw RE, et al. Recommendations for the establishment of primary stroke centers. Brain Attack Coalition. JAMA. 2000;283:3102–9.PubMedCrossRef
33.
Alberts MJ, Latchaw RE, Jagoda A, et al. Revised and updated recommendations for the establishment of primary stroke centers: a summary statement from the brain attack coalition. Stroke. 2011;42:2651–65.PubMedCrossRef
34.
Alberts MJ, Latchaw RE, Selman WR, et al. Recommendations for comprehensive stroke centers: a consensus statement from the Brain Attack Coalition. Stroke. 2005;36:1597–616.PubMedCrossRef
35.
Qureshi AI, Suri MF, Nasar A, et al. Thrombolysis for ischemic stroke in the United States: data from National Hospital Discharge Survey 1999-2001. Neurosurgery. 2005;57:647–54.PubMedCrossRef
36.
Smith WS, Sung G, Starkman S, et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke. 2005;36:1432–8.PubMedCrossRef
37.
Bose A, Henkes H, Alfke K, et al. The Penumbra System: a mechanical device for the treatment of acute stroke due to thromboembolism. AJNR Am J Neuroradiol. 2008;29:1409–13.PubMedCrossRef
38.
Smith WS, Sung G, Saver J, et al. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke. 2008;39:1205–12.PubMedCrossRef
39.
The Interventional Management of Stroke (IMS) II Study. Stroke 2007;38:2127-2135.
40.
Costalat V, Machi P, Lobotesis K, et al. Rescue, combined, and stand-alone thrombectomy in the management of large vessel occlusion stroke using the solitaire device: a prospective 50-Patient Single-Center Study: Timing, Safety, and Efficacy. Stroke 2011 May 19.
41.
Katzan IL, Masaryk TJ, Furlan AJ, et al. Intra-arterial thrombolysis for perioperative stroke after open heart surgery. Neurology. 1999;52:1081–4.PubMedCrossRef
42.
Nogueira RG, Smith WS. Safety and efficacy of endovascular thrombectomy in patients with abnormal hemostasis: pooled analysis of the MERCI and multi MERCI trials. Stroke. 2009;40:516–22.PubMedCrossRef
43.
Meyers PM, Schumacher HC, Higashida RT, et al. Indications for the performance of intracranial endovascular neurointerventional procedures: a scientific statement from the American Heart Association Council on Cardiovascular Radiology and Intervention, Stroke Council, Council on Cardiovascular Surgery and Anesthesia, Interdisciplinary Council on Peripheral Vascular Disease, and Interdisciplinary Council on Quality of Care and Outcomes Research. Circulation. 2009;119:2235–49.PubMedCrossRef
44.
Barnwell SL, Clark WM, Nguyen TT, O'Neill OR, Wynn ML, Coull BM. Safety and efficacy of delayed intraarterial urokinase therapy with mechanical clot disruption for thromboembolic stroke. AJNR Am J Neuroradiol. 1994;15:1817–22.PubMed
45.
Jovin TG, Liebeskind DS, Gupta R, et al. Imaging-based endovascular therapy for acute ischemic stroke due to proximal intracranial anterior circulation occlusion treated beyond 8 hours from time last seen well: retrospective multicenter analysis of 237 consecutive patients. Stroke. 2011;42:2206–11.PubMedCrossRef
46.
•• 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;380:1241-9. A randomized trial that compared the Merci™ retriever with a stent-retriever that was stopped early due to a marked benefit in recanalization, safety, good outcomes, and mortality in favor of the latest generation device (Solitaire FR™).
47.
•• 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;380:1231-40. The second randomized trial that showed superiority of a stent-retriever over the older Merci™ embolectomy device.
48.
Jovin TG, Gupta R, Uchino K, et al. Emergent stenting of extracranial internal carotid artery occlusion in acute stroke has a high revascularization rate. Stroke. 2005;36:2426–30.PubMedCrossRef
49.
Gupta R, Tayal AH, Levy EI, et al. Intra-arterial thrombolysis or stent placement during endovascular treatment for acute ischemic stroke leads to the highest recanalization rate: results of a multicenter retrospective study. Neurosurgery. 2011;68:1618–22.PubMedCrossRef
50.
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;69:915–20.PubMedCrossRef
51.
Adams Jr HP, Brott TG, Furlan AJ, et al. Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association. Circulation. 1996;94:1167–74.PubMedCrossRef
52.
Juttler E, Schwab S, Schmiedek P, et al. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke. 2007;38:2518–25.PubMedCrossRef
53.
Rahme R, Zuccarello M, Kleindorfer D, Adeoye OM, Ringer AJ. Decompressive hemicraniectomy for malignant middle cerebral artery territory infarction: is life worth living? J Neurosurg. 2012;117:749–54.PubMedCrossRef
54.
Zhao J, Su YY, Zhang Y, et al. Decompressive hemicraniectomy in malignant middle cerebral artery infarct: a randomized controlled trial enrolling patients up to 80 years old. Neurocrit Care. 2012;17:161–71.PubMedCrossRef
55.
McKenna A, Wilson CF, Caldwell SB, Curran D. Functional outcomes of decompressive hemicraniectomy following malignant middle cerebral artery infarctions: a systematic review. Br J Neurosurg. 2012;26:310–5.PubMedCrossRef
56.
Bershad EM, Feen ES, Hernandez OH, Suri MF, Suarez JI. Impact of a specialized neurointensive care team on outcomes of critically ill acute ischemic stroke patients. Neurocrit Care. 2008;9:287–92.PubMedCrossRef
Metadata
Title
Management of Acute Ischemic Stroke
Author
Alex Abou-Chebl
Publication date
01-04-2013
Publisher
Current Science Inc.
Published in
Current Cardiology Reports / Issue 4/2013
Print ISSN: 1523-3782
Electronic ISSN: 1534-3170
DOI
https://doi.org/10.1007/s11886-013-0348-4

Other articles of this Issue 4/2013

Current Cardiology Reports 4/2013 Go to the issue

Ischemic Heart Disease (D Mukherjee, Section Editor)

HDL Cholesterol and Cardiovascular Outcomes: What Is the Evidence?

Peripheral Vascular Disease (M Shishehbor, Section Editor)

Functional Impairment in Peripheral Artery Disease and How to Improve It in 2013

Interventional Cardiology (S Rao, Section Editor)

Identification and Management of Complications of Transradial Procedures

Valvular Heart Disease (V Nkomo, Section Editor)

Transcatheter Aortic Valve Replacement: Current Application and Future Directions

Nuclear Cardiology (V Dilsizian, Section Editor)

18F-FDG PET/CT for the Assessment of Myocardial Sarcoidosis

Interventional Cardiology (S Rao, Section Editor)

Combining PCI and CABG: the Role of Hybrid Revascularization