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

Nature Clinical Practice Neurology volume 3, pages 45–53 (2007)Cite this article

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.

Key Points

  • Intravenous recombinant tissue plasminogen activator (rtPA) has been shown to improve outcome in patients with ischemic stroke if given within the first 3 hours, and perhaps up to 4.5 hours

  • Strokes from large-vessel intracranial occlusion carry high morbidity and respond poorly to intravenously administered thrombolytics

  • Intra-arterial thrombolytics significantly restore perfusion within intracranial large arteries, particularly the middle cerebral artery, but no drug is FDA approved for this use

  • Mechanical thrombectomy significantly restores patency in large-vessel stroke, and revascularization portends better clinical outcome

  • Mechanical thrombectomy can be safely combined with intravenous and intra-arterial thrombolytic treatments

  • The exact selection of treatment modalities is probably patient-specific, and is the subject of ongoing investigations

  • The marriage of primary and comprehensive stroke centers in the US is likely to be a viable solution to bring state-of-the-art stroke treatment to anyone with acute stroke

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Figure 1: The mechanical clot retriever.
Figure 2: Outcome of mechanical clot retrieval.
Figure 3: Algorithm used at the University of California, San Francisco for patients with acute ischemic stroke.

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Author notes

  1. Department of Neurology, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0114, USA smithw@neurology.ucsf.edu

Authors and Affiliations

  1. WS Smith is Professor of Neurology and Daryl R Gress Endowed Chair of Neurocritical Care and Stroke at the University of California, San Francisco, CA, USA.,

    Wade S Smith

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Competing interests

The author has declared associations with the following company: Concentric Medical.

WS Smith owns stock in Concentric Medical.

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Smith, W. Technology Insight: recanalization with drugs and devices during acute ischemic stroke. Nat Rev Neurol 3, 45–53 (2007). https://doi.org/10.1038/ncpneuro0372

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