Pharmacologic and Medical Management in the Setting of Endovascular Stroke Interventions: A Comprehensive Overview to Management

Abstract

Endovascular therapy (EVT) has transformed acute ischemic stroke management, achieving successful vessel recanalization in approximately 70 to 80% of patients. Despite these advances, recommendations regarding medical management in the setting of EVT remain complex and variable across institutions. In keeping, this work presents a comprehensive overview of medical management in the setting of EVT is presented to provide direction and clarity regarding essential components of management, thus promoting positive outcomes and minimizing morbidity/mortality. In the preprocedural setting, intravenous thrombolysis remains standard therapy for eligible patients, while periprocedural anticoagulation and antiplatelet therapies are generally discouraged due to increased risk of hemorrhage and lack of functional benefit, with select exceptions such as emergency stenting for tandem lesions. Postprocedural blood pressure management should be individualized, with consensus favoring systolic blood pressure targets below 160 mm Hg after reperfusion, noting that higher targets (up to 180 mm Hg) may be considered in cases of incomplete reperfusion, and excessively low targets (<120 mm Hg) may be detrimental to maintaining adequate cerebral perfusion. Ongoing research is refining optimal management strategies to improve outcomes in this population further.

Keywords

endovascular therapy - acute ischemic stroke - pharmacologic management - anticoagulation - medical management

Publikationsverlauf

Artikel online veröffentlicht:
05. November 2025

• References

• 1 Demaerschalk BM, Kleindorfer DO, Adeoye OM. et al; American Heart Association Stroke Council and Council on Epidemiology and Prevention. Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2016; 47 (02) 581-641
• 2 Tsao CW, Aday AW, Almarzooq ZI. et al; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2023 update: a report from the American Heart Association. Circulation 2023; 147 (08) e93-e621
• 3 Powers WJ, Rabinstein AA, Ackerson T. et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2019; 50 (12) e344-e418
• 4 Goyal M, Menon BK, van Zwam WH. et al; HERMES collaborators. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 2016; 387 (10029): 1723-1731
• 5 Virani SS, Alonso A, Aparicio HJ. et al; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2021 update: a report from the American Heart Association. Circulation 2021; 143 (08) e254-e743
• 6 Astrup J, Siesjö BK, Symon L. Thresholds in cerebral ischemia - the ischemic penumbra. Stroke 1981; 12 (06) 723-725
• 7 Dirnagl U, Iadecola C, Moskowitz MA. Pathobiology of ischaemic stroke: an integrated view. Trends Neurosci 1999; 22 (09) 391-397
• 8 Lakhan SE, Kirchgessner A, Hofer M. Inflammatory mechanisms in ischemic stroke: therapeutic approaches. J Transl Med 2009; 7: 97
• 9 Adams Jr HP, Bendixen BH, Kappelle LJ. et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993; 24 (01) 35-41
• 10 Benjamin EJ, Blaha MJ, Chiuve SE. et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation 2017; 135 (10) e146-e603
• 11 Caplan LR, Gorelick PB, Hier DB. Race, sex and occlusive cerebrovascular disease: a review. Stroke 1986; 17 (04) 648-655
• 12 Hart RG, Diener HC, Coutts SB. et al; Cryptogenic Stroke/ESUS International Working Group. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol 2014; 13 (04) 429-438
• 13 Wardlaw JM, Murray V, Berge E, del Zoppo GJ. Thrombolysis for acute ischaemic stroke. Cochrane Database Syst Rev 2014; 2014 (07) CD000213
• 14 Hacke W, Kaste M, Bluhmki E. et al; ECASS Investigators. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359 (13) 1317-1329
• 15 Ankolekar S, Tomson J, Dixit A. et al. Tenecteplase versus alteplase for thrombolysis in acute ischaemic stroke (ATTEST-2): a randomised, open-label, parallel-group, non-inferiority trial. Lancet 2025; 405: 195-205
• 16 Wang Y, Li S, Pan Y. et al. Tenecteplase versus alteplase in acute ischaemic stroke (ORIGINAL): a randomised, controlled, open-label, blinded endpoint, non-inferiority trial. Lancet 2024; 404: 1549-1559
• 17 Katsanos AH, Safouris A, Sarraj A. et al. Intravenous thrombolysis with tenecteplase in patients with large vessel occlusions: systematic review and meta-analysis. Stroke 2021; 52 (01) 308-312
• 18 Burgos AM, Saver JL. Evidence that tenecteplase is noninferior to alteplase for acute ischemic stroke: meta-analysis of 5 randomized trials. Stroke 2019; 50 (08) 2156-2162
• 19 Kleindorfer DO, Towfighi A, Chaturvedi S. et al. 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline from the American Heart Association/American Stroke Association. Stroke 2021; 52 (07) e364-e467
• 20 Fugate JE, Rabinstein AA. Absolute and relative contraindications to IV rt-PA for acute ischemic stroke. Neurohospitalist 2015; 5 (03) 110-121
• 21 Ma H, Campbell BCV, Parsons MW. et al; EXTEND Investigators. Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke. N Engl J Med 2019; 380 (19) 1795-1803
• 22 Jauch EC, Saver JL, Adams Jr HP. et al; American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44 (03) 870-947
• 23 Logallo N, Novotny V, Assmus J. et al. Tenecteplase versus alteplase for management of acute ischaemic stroke (NOR-TEST): a phase 3, randomised, open-label, blinded endpoint trial. Lancet Neurol 2017; 16 (10) 781-788
• 24 Campbell BCV, Mitchell PJ, Churilov L. et al; EXTEND-IA TNK Investigators. Tenecteplase versus alteplase before thrombectomy for ischemic stroke. N Engl J Med 2018; 378 (17) 1573-1582
• 25 Whiteley WN, Emberson J, Lees KR. et al; Stroke Thrombolysis Trialists' Collaboration. Risk of intracerebral haemorrhage with alteplase after acute ischaemic stroke: a secondary analysis of an individual patient data meta-analysis. Lancet Neurol 2016; 15 (09) 925-933
• 26 Malhotra K, Liebeskind DS, Demchuk AM. et al. Malignant blood pressure after mechanical thrombectomy for acute ischemic stroke. Neurology 2018; 90: e1428-e1434
• 27 Anadani M, Orabi MY, Alawieh A. et al. Blood pressure and outcome after mechanical thrombectomy with successful revascularization. Stroke 2019; 50 (09) 2448-2454
• 28 Texakalidis P, Rizzo A, Sweid A. et al. Optimal blood pressure during mechanical thrombectomy for acute ischemic stroke: a systematic review and meta-analysis. J Neurointerv Surg 2019; 11: 1202-1210
• 29 Jovin TG, Nogueira RG, Lansberg MG. et al. Thrombectomy for anterior circulation stroke beyond 6 h from symptom onset. N Engl J Med 2022; 387: 1977-1988
• 30 Berkhemer OA, Fransen PS, Beumer D. et al; MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372 (01) 11-20
• 31 Goyal M, Demchuk AM, Menon BK. et al; ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015; 372 (11) 1019-1030
• 32 Saver JL, Goyal M, Bonafe A. et al; SWIFT PRIME Investigators. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015; 372 (24) 2285-2295
• 33 Campbell BC, Mitchell PJ, Kleinig TJ. et al; EXTEND-IA Investigators. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015; 372 (11) 1009-1018
• 34 Jovin TG, Chamorro A, Cobo E. et al; REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015; 372 (24) 2296-2306
• 35 Tsivgoulis G, Campbell BC. Endovascular thrombectomy for large core ischemic stroke-age matters. JAMA Netw Open 2024; 7 (08) e2425958
• 36 Nogueira RG, Jadhav AP, Haussen DC. et al; DAWN Trial Investigators. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 2018; 378 (01) 11-21
• 37 Albers GW, Marks MP, Kemp S. et al; DEFUSE 3 Investigators. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 2018; 378 (08) 708-718
• 38 Sarraj A, Hassan AE, Abraham MG. et al; SELECT2 Investigators. Trial of endovascular thrombectomy for large ischemic strokes. N Engl J Med 2023; 388 (14) 1259-1271
• 39 Yoshimura S, Sakai N, Yamagami H. et al. Endovascular therapy for acute stroke with a large ischemic region. N Engl J Med 2022; 386 (14) 1303-1313
• 40 Huo X, Ma G, Tong X. et al; ANGEL-ASPECT Investigators. Trial of endovascular therapy for acute ischemic stroke with large infarct. N Engl J Med 2023; 388 (14) 1272-1283
• 41 Davenport MS, Cohan RH, Caoili EM, Ellis JH. Repeat contrast medium reactions in premedicated patients: frequency and severity. Radiology 2009; 253 (02) 372-379
• 42 Wang CL, Cohan RH, Ellis JH, Adusumilli S, Dunnick NR. Frequency, management, and outcome of extravasation of nonionic iodinated contrast medium in 69,657 intravenous injections. Radiology 2007; 243 (01) 80-87
• 43 LeCouffe NE, Kappelhof M, Treurniet KM. et al; MR CLEAN–NO IV Investigators. A randomized trial of intravenous alteplase before endovascular treatment for stroke. N Engl J Med 2021; 385 (20) 1833-1844
• 44 Wischmann J, Hamann GF, Kahl A. et al. Heparin versus no heparin during endovascular therapy with stent retrievers for acute ischemic stroke: a matched comparison. Stroke 2021; 52: 1580-1588
• 45 Wang A, Abramson RG, Kamel H. et al. Association of intraprocedural heparin with outcomes after endovascular therapy for acute ischemic stroke. Stroke 2023; 54: 1200-1207
• 46 Saver JL, Goyal M, van der Lugt A. et al; HERMES Collaborators. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA 2016; 316 (12) 1279-1288
• 47 Matsubara H, Nishiyama Y, Katayama Y. et al. Effects of anticoagulant administration on recanalization therapy for acute ischemic stroke with large-vessel occlusion. J Neurosurg 2020; 132: 1834-1841
• 48 Bernsen MLE, Goldhoorn RB, Lingsma HF. et al. Effect of parenteral anticoagulation on outcome after endovascular treatment for acute ischemic stroke. Stroke 2019; 50: 1233-1236
• 49 Sallustio F, Motta C, Pizzuto S. et al. Periprocedural antithrombotic treatment and outcome after endovascular stroke treatment. J Stroke Cerebrovasc Dis 2020; 29: 104567
• 50 Turc G, Bhogal P, Fischer U. et al. European Stroke Organisation (ESO)- European Society for Minimally Invasive Neurological Therapy (ESMINT) guidelines on mechanical thrombectomy in acute ischemic stroke. J Neurointerv Surg 2019; 11 (06) 535-538
• 51 Boulanger JM, Lindsay MP, Gubitz G. et al. Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018. Int J Stroke 2018; 13: 949-984
• 52 Petersen NH, Silverman A, Strander SM. et al. Fixed compared with autoregulation-oriented blood pressure thresholds after mechanical thrombectomy for ischemic stroke. Stroke 2020; 51 (03) 914-921
• 53 Kellert L, Hametner C, Ahmed N. et al. Reciprocal interaction of 25-hydroxyvitamin D and omega-3 polyunsaturated fatty acids on inflammatory markers in patients with acute ischemic stroke. Stroke 2014; 45: 3214-3219
• 54 Kang DH, Park J. Endovascular stroke therapy focused on stent retriever thrombectomy and direct aspiration: historical review and modern application. J Korean Neurosurg Soc 2017; 60 (03) 335-347
• 55 Goldstein LB, Bushnell CD, Adams RJ. et al; American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Epidemiology and Prevention, Council for High Blood Pressure Research, Council on Peripheral Vascular Disease, and Interdisciplinary Council on Quality of Care and Outcomes Research. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011; 42 (02) 517-584
• 56 Werring DJ, Dehbi HM, Ahmed N. et al; OPTIMAS investigators. Optimal timing of anticoagulation after acute ischaemic stroke with atrial fibrillation (OPTIMAS): a multicentre, blinded-endpoint, phase 4, randomised controlled trial. Lancet 2024; 404: 1027-1039
• 57 Polymeris AA, Meinel TR, Rubiera M. et al. Prior reperfusion strategy does not modify outcome in early versus late start of anticoagulants in patients with ischemic stroke: prespecified subanalysis of the randomized controlled ELAN trial. Stroke 2024; 55: 3085-3093
• 58 Åsberg S, Farahmand B, Henriksson KM. et al. Early versus delayed non–vitamin K antagonist oral anticoagulant therapy after acute ischemic stroke in atrial fibrillation (TIMING): a registry-based randomized controlled noninferiority study. Circulation 2022; 146: 561-569
• 59 King BT, Lawrence PD, Milling TJ, Warach SJ. Optimal delay time to initiate anticoagulation after ischemic stroke in atrial fibrillation (START): methodology of a pragmatic, response-adaptive, prospective randomized clinical trial. Int J Stroke 2019; 14 (09) 977-982
• 60 Yaghi S, D'Amelio M, Wilson D. et al. Collaboration on the optimal timing of anticoagulation after ischemic stroke in atrial fibrillation (CATALYST). Stroke 2025; 56: e300-e305
• 61 Powers WJ. Acute ischemic stroke. N Engl J Med 2020; 383 (03) 252-260
• 62 Ghozy S, Mortezaei A, Elfil M. et al. Intensive vs conventional blood pressure control after thrombectomy in acute ischemic stroke: a systematic review and meta-analysis. JAMA Netw Open 2024; 7 (02) e240179
• 63 Minhas JS, Wang X, Lavados PM. et al; HeadPoST Investigators. Blood pressure variability and outcome in acute ischemic and hemorrhagic stroke: a post hoc analysis of the HeadPoST study. J Hum Hypertens 2019; 33 (05) 411-418
• 64 Mistry EA, Mistry AM, Korte S. et al. Blood pressure after endovascular stroke therapy: the BEST-II randomized clinical trial. JAMA Neurol 2023; 80: 1010-1019
• 65 Mistry EA, Mistry AM, de Havenon A. et al. Individualized blood pressure reduction after successful endovascular therapy: the OPTIMAL_BP randomized clinical trial. JAMA Neurol 2023; 80: 1020-1029
• 66 Anderson CS, Huang Y, Lindley RI. et al. Intensive blood pressure lowering in acute cerebral haemorrhage 2 (ENCHANTED2/ICH): a multicentre, open-label, blinded-endpoint, randomised trial. Lancet 2022; 400: 1615-1626
• 67 Baek JM, Yoo J, Song D. et al. Intra-arterial tirofiban infusion for partial recanalization with stagnant flow in hyperacute cerebral ischemic stroke. Interv Neuroradiol 2018; 24: 244-249
• 68 Bourcier R, Saleme S, Labreuche J. et al; ASTER Trial Investigators. More than three passes of stent retriever is an independent predictor of parenchymal hematoma in acute ischemic stroke. J Neurointerv Surg 2019; 11 (07) 625-629
• 69 Kellert L, Hametner C, Ahmed N. et al. Complications and safety of endovascular treatment. Curr Treat Options Neurol 2018; 20: 6
• 70 Boulanger JM, Lindsay MP, Gubitz G. et al. Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018. Stroke 2018; 49: 1072-1093
• 71 Raimondi P, Hylek EM, Aronis KN. Reversal agents for oral antiplatelet and anticoagulant treatment during bleeding events: current strategies. Curr Pharm Des 2017; 23 (09) 1406-1423
• 72 Frontera JA, Lewin III JJ, Rabinstein AA. et al. Guideline for reversal of antithrombotics in intracranial hemorrhage: a statement for healthcare professionals from the Neurocritical Care Society and Society of Critical Care Medicine. Neurocrit Care 2016; 24 (01) 6-46
• 73 Jehan F, Zeeshan M, Kulvatunyou N. et al. Is there a need for platelet transfusion after traumatic brain injury in patients on P2Y12 inhibitors?. J Surg Res 2019; 236: 224-229
• 74 Writing Committee for the PEARL Investigators, PEARL investigators. Intra-Arterial Alteplase After Successful Endovascular Reperfusion in Acute Stroke: The PEARL Randomized Clinical Trial. JAMA. Published online October 13, 2025. doi:10.1001/jama.2025.16876