Catheter-based interventions for acute ischaemic stroke currently include clot removal (usually from the medial cerebral artery) with modern stent-retrievers and in one of five patients (who have simultaneous or stand-alone internal carotid occlusion) also extracranial carotid intervention. Several recently published randomized trials clearly demonstrated superiority of catheter-based interventions (with or without bridging thrombolysis) over best medical therapy alone. The healthcare systems should adopt the new strategies for acute stroke treatment (including fast track to interventional lab) to offer the benefits to all suitable acute stroke patients.

• Keywords
• Acute stroke *, Catheter intervention *, Neurologic outcome *, Stent-retriever *, Thrombectomy *,
• MeSH
• Arterial Occlusive Diseases MeSH
• Stroke * MeSH
• Brain Ischemia MeSH
• Humans MeSH
• Stents MeSH
• Thrombectomy MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Review MeSH

The evolution of reperfusion therapy in acute myocardial infarction and acute ischaemic stroke has many similarities: thrombolysis is superior to placebo, intra-arterial thrombolysis is not superior to intravenous (i.v.), facilitated intervention is of questionable value, and direct mechanical recanalization without thrombolysis is proven (myocardial infarction) or promising (stroke) to be superior to thrombolysis-but only when started with no or minimal delay. However, there are also substantial differences. Direct catheter-based thrombectomy in acute ischaemic stroke is more difficult than primary angioplasty (in ST-elevation myocardial infarction [STEMI]) in many ways: complex pre-intervention diagnostic workup, shorter time window for clinically effective reperfusion, need for an emergent multidisciplinary approach from the first medical contact, vessel tortuosity, vessel fragility, no evidence available about dosage and combination of peri-procedural antithrombotic drugs, risk of intracranial bleeding, unclear respective roles of thrombolysis and mechanical intervention, lower number of suitable patients, and thus longer learning curves of the staff. Thus, starting acute stroke interventional programme requires a lot of learning, discipline, and humility. Randomized trials comparing different reperfusion strategies provided similar results in acute ischaemic stroke as in STEMI. Thus, it might be expected that also a future randomized trial comparing direct (primary) catheter-based thrombectomy vs. i.v. thrombolysis could show superiority of the mechanical intervention if it would be initiated without delay. Such randomized trial is needed to define the role of mechanical intervention alone in acute stroke treatment.

• Keywords
• Acute stroke, Catheter intervention, Myocardial infarction, Primary angioplasty, Reperfusion, Thrombectomy, Thrombolysis,
• MeSH
• Acute Disease MeSH
• Stroke therapy   MeSH
• Fibrinolytic Agents therapeutic use   MeSH
• Myocardial Infarction therapy   MeSH
• Infusions, Intravenous MeSH
• Clinical Trials as Topic MeSH
• Combined Modality Therapy MeSH
• Percutaneous Coronary Intervention methods   MeSH
• Humans MeSH
• Reperfusion methods   MeSH
• Thrombectomy methods   MeSH
• Thrombolytic Therapy methods   MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Research Support, Non-U.S. Gov't MeSH
• Review MeSH
• Names of Substances
• Fibrinolytic Agents MeSH

Ischemic stroke is most often caused by an acute extracranial or intracranial thromboembolic lesion obstructing an artery. It has been demonstrated that recanalization is the most important modifiable predictor of a good clinical outcome. Reperfusion strategies focus on early reopening of the vessel to reestablish antegrade flow within the penumbra.Current standard therapy within 4.5 h is intravenous thrombolysis (IVT) with tissue plasminogen activator (tPA, 0.9 mg/kg body weight, maximum dose 90 mg). Thrombolytic therapy appears to be safe and effective across various types of hospitals, if the treatment is conducted by a physician with stroke expertise.New imaging methods (MR diffusion/perfusion, CT perfusion) are being investigated in order to better select patients who are most likely to benefit from recanalization therapy based on current clinical evidence. Neither perfusion imaging with CT or MR nor the mismatch concept are recommended for routine treatment decisions within or beyond the 4.5 h available for IVT.If major vessel occlusion is proven but IVT is contraindicated, intra-arterial thrombolysis (IAT) with tPA or mechanical thrombectomy with the Merci Retriever or Penumbra System may be a treatment option. The availability of IAT generally should not preclude the intravenous administration of tPA in otherwise eligible patients. Intra-arterial treatment can be performed within 8 h after stroke onset. Combining intravenous tPA pretreatment with subsequent IAT or mechanical thrombectomy may improve the recanalization rate and may be used as a rescue therapy in cases of persistent major vessel occlusion after unsuccessful IVT.Despite testing, no thrombolytic agent other than tPA (e.g., IIb/IIIa antagonists, heparin, etc.) has yet been approved for routine practice for either intravenous or intra-arterial application, alone or in combination with tPA.Continuous transcranial Doppler (TCD) monitoring of an occluded vessel may increase the rate of early recanalization after tPA; this effect may be facilitated by the administration of microbubbles. This method is still considered experimental.

• Publication type
• Journal Article MeSH