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Stroke Therapy
Jared Halpin, MD; Coleman O. Martin, MD
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Post Procedure

          TERMINOLOGY

          • Definitions

            • Stroke: Acute loss of brain function(s) due to disturbance in blood supply to brain
              • Ischemic stroke: Embolic or thrombotic occlusion of arterial supply to brain (80% of strokes)
                • 3 major clinical ischemic stroke subtypes
                  • Large artery/atherosclerotic strokes (40-50%)
                  • Cardioembolic disease (20-25%)
                  • Lacunar infarction (20-30%)
              • Hemorrhagic stroke: Rupture/bleeding from brain blood vessel (15% of strokes)
              • Nontraumatic subarachnoid hemorrhage (5%)
              • Vasculitis
              • Venous infarction (< 1%)
            • Core infarct: Central area of severe ischemia/evolving infarction; unlikely to respond to treatment
              • Severely reduced to almost nonexistent blood flow
              • Inadequate supply of oxygen and glucose
              • Neuronal and glial necrosis
                • Irreversible damage; no response to reperfusion
            • Ischemic penumbra: Surrounding rim of ischemic tissue between normally perfused tissue and area of evolving infarction
              • Parenchymal tissue at risk of eventual infarction
                • Dependent upon collateral perfusion
                • Collateral circulation inadequate to maintain neuronal oxygen/glucose demand indefinitely
              • May remain viable for several hours
              • Target of acute stroke intervention
            • Endovascular therapy (ET): New standard of care for acute ischemic stroke with emergent large vessel occlusion (ELVO)
              • Potential reperfusion techniques
                • Intravenous thrombolysis [IV tissue plasminogen activator (tPA)]
                • Mechanical thrombectomy (stent retriever, aspiration catheter)
                • Balloon angioplasty/stenting
                • Intraarterial thrombolysis
            • Stroke-related scales/grades
              • National Institutes of Health Stroke Scale (NIHSS)
                • Clinical assessment tool used to quantify neurologic impairment caused by acute stroke
                • Predictor of short- and long-term outcome

          PREPROCEDURE

          • Indications

            • Contraindications

              • Preprocedure Imaging

                • Getting Started

                  PROCEDURE

                  • Patient Position/Location

                    • Procedure Steps

                      • Findings and Reporting

                        • Alternative Procedures/Therapies

                          POST PROCEDURE

                          • Things to Do

                            OUTCOMES

                            • Complications

                              • Management of Complications

                                • Expected Outcomes

                                  Selected References

                                  1. Berkhemer OA et al: A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 372(1):11-20, 2015
                                  2. Goyal M et al: Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 372(11):1019-30, 2015
                                  3. Saver JL et al: Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 372(24):2285-95, 2015
                                  4. Sheth SA et al: M2 occlusions as targets for endovascular therapy: comprehensive analysis of diffusion/perfusion MRI, angiography, and clinical outcomes. J Neurointerv Surg. 7(7):478-83, 2015
                                  5. Campbell BC et al: A multicenter, randomized, controlled study to investigate EXtending the time for Thrombolysis in Emergency Neurological Deficits with Intra-Arterial therapy (EXTEND-IA). Int J Stroke. 9(1):126-32, 2014
                                  6. Nguyen TN et al: Balloon guide catheter improves revascularization and clinical outcomes with the Solitaire device: analysis of the North American Solitaire Acute Stroke Registry. Stroke. 45(1):141-5, 2014
                                  7. Davis MJ et al: Anesthetic management and outcome in patients during endovascular therapy for acute stroke. Anesthesiology. 116(2):396-405, 2012
                                  8. Saver JL et al: Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet. 380(9849):1241-9, 2012
                                  9. Konstas AA et al: CT perfusion imaging of acute stroke: the need for arrival time, delay insensitive, and standardized postprocessing algorithms? Radiology. 254(1):22-5, 2010
                                  10. Konstas AA et al: Theoretic basis and technical implementations of CT perfusion in acute ischemic stroke, part 1: Theoretic basis. AJNR Am J Neuroradiol. 30(4):662-8, 2009
                                  11. Konstas AA et al: Theoretic basis and technical implementations of CT perfusion in acute ischemic stroke, part 2: technical implementations. AJNR Am J Neuroradiol. 30(5):885-92, 2009
                                  12. Hurst RW et al: Interventional Neuroradiology. New York: Informa Healthcare, 2008
                                  13. Smith WS et al: Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke. 39(4):1205-12, 2008
                                  14. Gonzalez RG et al: Acute Ischemic Stroke: Imaging and Intervention. Berlin Heidelberg: Springer-Verlag, 2006
                                  15. Hacke W et al: Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA. 274(13):1017-25, 1995
                                  16. Bonita R et al: Recovery of motor function after stroke. Stroke. 19(12):1497-500, 1988
                                  17. van Swieten JC et al: Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 19(5):604-7, 1988
                                  18. Mahoney FI et al: Functional evaluation: the Barthel Index. Md State Med J. 14:61-5, 1965
                                  19. Rankin J: Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J. 2(5):200-15, 1957
                                  Related Anatomy
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                                  Related Differential Diagnoses
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                                  References
                                  Tables

                                  Tables

                                  KEY FACTS

                                  • Terminology

                                    • Preprocedure

                                      • Procedure

                                        • Post Procedure

                                          TERMINOLOGY

                                          • Definitions

                                            • Stroke: Acute loss of brain function(s) due to disturbance in blood supply to brain
                                              • Ischemic stroke: Embolic or thrombotic occlusion of arterial supply to brain (80% of strokes)
                                                • 3 major clinical ischemic stroke subtypes
                                                  • Large artery/atherosclerotic strokes (40-50%)
                                                  • Cardioembolic disease (20-25%)
                                                  • Lacunar infarction (20-30%)
                                              • Hemorrhagic stroke: Rupture/bleeding from brain blood vessel (15% of strokes)
                                              • Nontraumatic subarachnoid hemorrhage (5%)
                                              • Vasculitis
                                              • Venous infarction (< 1%)
                                            • Core infarct: Central area of severe ischemia/evolving infarction; unlikely to respond to treatment
                                              • Severely reduced to almost nonexistent blood flow
                                              • Inadequate supply of oxygen and glucose
                                              • Neuronal and glial necrosis
                                                • Irreversible damage; no response to reperfusion
                                            • Ischemic penumbra: Surrounding rim of ischemic tissue between normally perfused tissue and area of evolving infarction
                                              • Parenchymal tissue at risk of eventual infarction
                                                • Dependent upon collateral perfusion
                                                • Collateral circulation inadequate to maintain neuronal oxygen/glucose demand indefinitely
                                              • May remain viable for several hours
                                              • Target of acute stroke intervention
                                            • Endovascular therapy (ET): New standard of care for acute ischemic stroke with emergent large vessel occlusion (ELVO)
                                              • Potential reperfusion techniques
                                                • Intravenous thrombolysis [IV tissue plasminogen activator (tPA)]
                                                • Mechanical thrombectomy (stent retriever, aspiration catheter)
                                                • Balloon angioplasty/stenting
                                                • Intraarterial thrombolysis
                                            • Stroke-related scales/grades
                                              • National Institutes of Health Stroke Scale (NIHSS)
                                                • Clinical assessment tool used to quantify neurologic impairment caused by acute stroke
                                                • Predictor of short- and long-term outcome

                                          PREPROCEDURE

                                          • Indications

                                            • Contraindications

                                              • Preprocedure Imaging

                                                • Getting Started

                                                  PROCEDURE

                                                  • Patient Position/Location

                                                    • Procedure Steps

                                                      • Findings and Reporting

                                                        • Alternative Procedures/Therapies

                                                          POST PROCEDURE

                                                          • Things to Do

                                                            OUTCOMES

                                                            • Complications

                                                              • Management of Complications

                                                                • Expected Outcomes

                                                                  Selected References

                                                                  1. Berkhemer OA et al: A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 372(1):11-20, 2015
                                                                  2. Goyal M et al: Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 372(11):1019-30, 2015
                                                                  3. Saver JL et al: Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 372(24):2285-95, 2015
                                                                  4. Sheth SA et al: M2 occlusions as targets for endovascular therapy: comprehensive analysis of diffusion/perfusion MRI, angiography, and clinical outcomes. J Neurointerv Surg. 7(7):478-83, 2015
                                                                  5. Campbell BC et al: A multicenter, randomized, controlled study to investigate EXtending the time for Thrombolysis in Emergency Neurological Deficits with Intra-Arterial therapy (EXTEND-IA). Int J Stroke. 9(1):126-32, 2014
                                                                  6. Nguyen TN et al: Balloon guide catheter improves revascularization and clinical outcomes with the Solitaire device: analysis of the North American Solitaire Acute Stroke Registry. Stroke. 45(1):141-5, 2014
                                                                  7. Davis MJ et al: Anesthetic management and outcome in patients during endovascular therapy for acute stroke. Anesthesiology. 116(2):396-405, 2012
                                                                  8. Saver JL et al: Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet. 380(9849):1241-9, 2012
                                                                  9. Konstas AA et al: CT perfusion imaging of acute stroke: the need for arrival time, delay insensitive, and standardized postprocessing algorithms? Radiology. 254(1):22-5, 2010
                                                                  10. Konstas AA et al: Theoretic basis and technical implementations of CT perfusion in acute ischemic stroke, part 1: Theoretic basis. AJNR Am J Neuroradiol. 30(4):662-8, 2009
                                                                  11. Konstas AA et al: Theoretic basis and technical implementations of CT perfusion in acute ischemic stroke, part 2: technical implementations. AJNR Am J Neuroradiol. 30(5):885-92, 2009
                                                                  12. Hurst RW et al: Interventional Neuroradiology. New York: Informa Healthcare, 2008
                                                                  13. Smith WS et al: Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke. 39(4):1205-12, 2008
                                                                  14. Gonzalez RG et al: Acute Ischemic Stroke: Imaging and Intervention. Berlin Heidelberg: Springer-Verlag, 2006
                                                                  15. Hacke W et al: Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA. 274(13):1017-25, 1995
                                                                  16. Bonita R et al: Recovery of motor function after stroke. Stroke. 19(12):1497-500, 1988
                                                                  17. van Swieten JC et al: Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 19(5):604-7, 1988
                                                                  18. Mahoney FI et al: Functional evaluation: the Barthel Index. Md State Med J. 14:61-5, 1965
                                                                  19. Rankin J: Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J. 2(5):200-15, 1957