Download PDF
Semin intervent Radiol 2002; 19(4): 331-338
DOI: 10.1055/s-2002-36748
Copyright © 2002 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Acute Stroke Intervention

Colin P. Derdeyn, DeWitte T. Cross, III, Christopher J. Moran
  • Interventional Neuroradiology Service, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
Further Information

Publication History

Publication Date:
21 January 2003 (online)

Also available at
    Permissions and Reprints

ABSTRACT

Acute ischemic stroke is a common cause of death and disability. To date, the only therapy proven to be effective is to restore blood flow by pharmacological fibrinolysis within the first few hours of stroke onset. The margin of benefit in the clinical trials of fibrinolysis has been small, however. This is due in part to the risk of intracranial hemorrhage after fibrinolytic therapy. Furthermore, many patients with acute ischemic stroke are not candidates for this treatment because of late presentation. Consequently, better and safer methods for the rapid dissolution of occlusive thrombus and better methods of patient selection based on advanced imaging have become two complementary areas of very active investigation. In this article, we will review the pathophysiology of acute ischemic stroke, the current proven therapies-intravenous (IV) tissue plasminogen activator (t-PA) and intra-arterial pro-urokinase (pro-UK)-ongoing research involving physiological imaging for patient triage, and new endovascular methods of revascularization.

KEYWORD

Ischemic stroke - fibrinolysis - cerebral blood flow

REFERENCES

  • 1 Broderick J, Brott T, Kothari R. The Greater Cincinnati/ Northern Kentucky Stroke Study: preliminary first-ever and total incidence rates of stroke among blacks.  Stroke . 1998;  29 415-421
    PubMedSearch in Google Scholar
  • 2 Bogousslavsky J, Hachinski V C, Boughner D R. Cardiac and arterial lesions in transient ischemic attacks.  Arch Neurol . 1986;  43 223-228
    PubMedSearch in Google Scholar
  • 3 Jones T H, Morawetz R B, Crowell R M. Thresholds of focal cerebral ischemia in awake monkeys.  J Neurosurg . 1981;  54 773-782
    CrossrefPubMedSearch in Google Scholar
  • 4 Pulsinelli W A. Selective neuronal vulnerability: morphological and molecular characteristics.  Prog Brain Res . 1985;  63 29-37
    PubMedSearch in Google Scholar
  • 5 Zanette E M, Fieschi C, Bozzao L. Comparison of cerebral angiography and transcranial Doppler sonography in acute stroke.  Stroke . 1989;  20 899-903
    CrossrefPubMedSearch in Google Scholar
  • 6 Del Zoppo J G, Poeck K, Pessin M S. Recombinant tissue plasminogen activator in acute thrombotic and embolic stroke.  Ann Neurol . 1992;  32 78-86
    CrossrefPubMedSearch in Google Scholar
  • 7 Horowitz S H, Zito J L, Donnarumma R, Patel M, Alvir J. Computed tomographic-angiographic findings within the first five hours of cerebral infarction.  Stroke . 1991;  22 1245-1253
    PubMedSearch in Google Scholar
  • 8 Furlan A, Higashida R, Wechsler L. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism.  JAMA . 1999;  282 2003-2011
    CrossrefPubMedSearch in Google Scholar
  • 9 NINDS rt-PA Stroke Group. Tissue plasminogen activator for acute ischemic stroke.  N Engl J Med . 1995;  333 1581-1587
    CrossrefPubMedSearch in Google Scholar
  • 10 Sherman D G, Atkinson R P, Chippendale T. Intravenous ancrod for treatment of acute ischemic stroke: the STAT study: a randomized controlled trial. Stroke Treatment with Ancrod Trial.  JAMA . 2000;  283 2395-2403
    CrossrefPubMedSearch in Google Scholar
  • 11 Katzan I L, Furlan A J, Lloyd L E. Use of tissue-type plasminogen activator for acute ischemic stroke: the Cleveland area experience.  JAMA . 2000;  283 1151-1158
    CrossrefPubMedSearch in Google Scholar
  • 12 Hacke W, Kaste M, Fieschi C. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS).  JAMA . 1995;  274 1017-1025
    CrossrefPubMedSearch in Google Scholar
  • 13 Hacke W, Kaste M, Fieschi C. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators.  Lancet . 1998;  352 1245-1251
    CrossrefPubMedSearch in Google Scholar
  • 14 Clark W M, Wissman S, Albers G W. Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset. The ATLANTIS Study: a randomized controlled trial. Alteplase Thrombolysis for Acute Noninterventional Therapy in Ischemic Stroke.  JAMA . 1999;  282 2019-2026
    CrossrefPubMedSearch in Google Scholar
  • 15 Cross III T D, Derdeyn C P, Moran C J. Bleeding complications after basilar artery fibrinolysis with tissue plasminogen activator.  AJNR Am J Neuroradiol . 2001;  22 521-525
    PubMedSearch in Google Scholar
  • 16 Derdeyn C P. Physiological neuroimaging: Emerging clinical applications.  JAMA . 2001;  285 3065-3068
    CrossrefPubMedSearch in Google Scholar
  • 17 Ueda T, Sakaki S, Yuh W T, Nochide I, Ohta S. Outcome in acute stroke with successful intra-arterial thrombolysis and predictive value of initial single-photon emission-computed tomography.  J Cereb Blood Flow Metab . 1999;  19 99-108
    PubMedSearch in Google Scholar
  • 18 Umemura A, Suzuka T, Yamada K. Quantitative measurement of cerebral blood flow by 99mTc-HMPAO SPECT in acute ischaemic stroke: usefulness in determining therapeutic options.  J Neurol Neurosurg Psychiatry . 2000;  69 472-478
    CrossrefPubMedSearch in Google Scholar
  • 19 Firlik A D, Rubin G, Yonas H, Wechsler L R. Relation between cerebral blood flow and neurologic deficit resolution in acute ischemic stroke.  Neurology . 1998;  51 177-182
    PubMedSearch in Google Scholar
  • 20 Schlaug G, Benfield A, Baird A E. The ischemic penumbra: operationally defined by diffusion and perfusion MRI.  Neurology . 1999;  53 1528-1537
    PubMedSearch in Google Scholar
  • 21 Wolpert S M, Bruckmann H, Greenlee R. Neuroradiologic evaluation of patients with acute stroke treated with recombinant tissue plasminogen activator. The rt-PA Acute Stroke Study Group.  AJNR Am J Neuroradiol . 1993;  14 3-13
    PubMedSearch in Google Scholar
  • 22 Tomsick T, Brott T, Barsan W. Prognostic value of the hyperdense middle cerebral artery sign and stroke scale score before ultraearly thrombolytic therapy.  AJNR Am J Neuroradiol . 1996;  17 79-85
    PubMedSearch in Google Scholar
  • 23 NINDS t-PA Stroke Study Group. Generalized efficacy of t-PA for acute stroke. Subgroup analysis of the NINDS t-PA Stroke Trial.  Stroke . 1997;  28 2119-2125
    PubMedSearch in Google Scholar
  • 24 Alberts M J. for the rt-PA acute Stroke Study Group. A safety and efficacy study of intravenous rt-PA in patients with acute stroke. In: del Zoppo GJ, Mori E, Hacke W, eds. Thrombolytic Therapy in Acute Stroke II Berlin: Springer-Verlag 1993: 45-52
    Search in Google Scholar
  • 25 Bozzao L, Fantozzi L M, Bastianello S. Ischaemic supratentorial stroke: angiographic findings in patients examined in the very early phase.  J Neurol . 1989;  236 340-342
    PubMedSearch in Google Scholar
  • 26 Herrmann H C, Moliterno D J, Ohman E M. Facilitation of early percutaneous coronary intervention after reteplase with or without abciximab in acute myocardial infarction: results from the SPEED (GUSTO-4 Pilot) Trial.  J Am Coll Cardiol . 2000;  36 1489-1496
    CrossrefPubMedSearch in Google Scholar
  • 27 The EPIC Investigators. Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty. The EPIC Investigation.  N Engl J Med . 1994;  330 956-961
    CrossrefPubMedSearch in Google Scholar
  • 28 Ringer A J, Qureshi A I, Fessler R D, Guterman L R, Hopkins L N. Angioplasty of intracranial occlusion resistant to thrombolysis in acute ischemic stroke.  Neurosurgery . 2001;  48 1282-1288
    PubMedSearch in Google Scholar
  • 29 Bellon R J, Putman C M, Budzik R F. Rheolytic thrombectomy of the occluded internal carotid artery in the setting of acute ischemic stroke.  AJNR Am J Neuroradiol . 2001;  22 526-530
    PubMedSearch in Google Scholar
  • 30 Cross III T D, Moran C J, Akins P T. Collateral circulation and outcome after basilar artery thrombolysis.  AJNR Am J Neuroradiol . 1988;  19 1319-1323
    PubMedSearch in Google Scholar
  • 31 Barnwell S L, Clark W M, Nguyen T T. Safety and efficacy of delayed intraarterial urokinase therapy with mechanical clot disruption for thromboembolic stroke.  AJNR Am J Neuroradiol . 1994;  15 1817-1822
    PubMedSearch in Google Scholar
  • 32 Chalela J A, Katzan I, Liebeskind D S. Safety of intra-arterial thrombolysis in the postoperative period.  Stroke . 2001;  32 1365-1369
    CrossrefPubMedSearch in Google Scholar
  • 33 Lewandowski C A, Frankel M, Tomsick T A. Combined intravenous and intra-arterial r-TPA versus intra-arterial therapy of acute ischemic stroke: Emergency Management of Stroke (EMS) Bridging Trial.  Stroke . 1999;  30 2598-2605
    CrossrefPubMedSearch in Google Scholar