Intra-arterial Therapy in the Early Treatment of Acute Ischaemic Stroke

http://www.ejves.com/article/S1078-5884(15)00575-4/abstract

Intra-arterial Therapy in the Early Treatment of Acute Ischaemic Stroke

In 1995, intravenously administered recombinant tissue-type plasminogen activator (rtPA) was demonstrated to be effective as a treatment for acute ischaemic stroke provided it was commenced within 3 hours of stroke onset.1 In 2008, the ECASS-2 trial demonstrated that the time window for intravenous thrombolysis could be increased to 4.5 hours.2 More recently, intra-arterial thrombectomy (IAT), in addition to intravenous rtPA, has been shown to be highly beneficial when administered within 6 hours after acute stroke onset in six randomized clinical trials.

The introduction of IAT may also increase the need for expedited carotid interventions such as endarterectomy or stenting. It may be challenging for interventionists to stent a severe stenosis of the extracranial carotid artery at the same time as they treat an occluded intracranial artery. From a pragmatic point of view, this may seem a good approach, but it is unknown if the patient will benefit from a simultaneous procedure, or if it would be better to perform deferred carotid surgery after a few days. In the Mr Clean study, additional carotid interventions were performed in one out of eight patients (13%) who were treated with thrombolysis. It is well known that carotid endarterectomy should be performed within a few days after onset of a TIA or minor disabling stroke, but we know little about the safety of this procedure in patients with a severe carotid artery stenosis who only very recently suffered from a major stroke that was successfully treated with IAT. Expedited carotid surgery within 24 hours of lysis completion has shown promising results, but more data on stenting versus surgery and especially the optimal timing are still required.

In summary, 2015 will be remembered as the year in which IAT was established as a highly beneficial therapy for patients with acute ischaemic stroke affecting the anterior circulation. Stroke teams should now move to implement IAT in their treatment strategies and adapt their organization accordingly. More knowledge about the best indications for IAT and the need for additional carotid interventions will be forthcoming in the future.