Ischemic stroke – novel therapeutic strategies

Authors


Elisabeth Farbu, Department of Neurology, Stavanger University Hospital, Stavanger, Norway
Tel.: +4751518447
Fax: +4751519916
e-mail: elfa@sus.no

Abstract

Farbu E, Kurz KD, Kurz MW. Ischemic stroke – novel therapeutic strategies.
Acta Neurol Scand: 2011: 124 (Suppl. 191): 28–37.
© 2011 John Wiley & Sons A/S.

Objectives –  Treatment of acute, ischemic stroke has changed markedly during the last two decades. We review existing data for optimizing modern stroke care.

Results –  Implementation of stroke units, giving systematic treatment and observation to stroke patients, has lead to a significant reduction in death and dependency. Introduction of intravenous rt-PA (IVT) within 3 h for selected stroke patients and recent extension of the time window to 4.5 h improved the outcome even further. Still, one must consider that IVT has several limitations, such as a narrow time window and several contraindications, and the effect is modest, particularly in strokes with a large vessel occlusion. Recanalization of the occluded vessel is a major predictor for good outcome and should be set as a goal. Intra-arterial rt-PA (IAT) and the concept of bridging therapy (IVT prior to IAT or thrombectomy with a mechanical device) may improve recanalization rates and outcome. Randomized controlled trials (RCT) are available for IAT, but not for thrombectomy with devices, and we mostly have retrospective non-controlled data. The Merci- and Penumbra system are the most studied devices, for which recent studies report acceptable safety and efficacy.

Conclusions –  Sufficiently powered RCTs to evaluate the effect of thrombectomy with mechanical devices are warranted, but as the natural course of a large vessel stroke carries a devastating prognosis, a proactive recanalization approach is justified based on today’s knowledge.

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