Endovascular Management of Acute Ischemic Stroke

Stroke is a major cause of serious, long-term disability and the third leading cause of death in the United States1. According to the World Health Organization, 15 million people suffer a stroke worldwide annually. Of those, one third do not survive and another third is left with a significant neurological deficit. The majority of these events are ischemic (87%), as opposed to intracerebral (10%) and subarachnoid hemorrhages (3%)1. Management of acute ischemic stroke was previously geared toward prevention, supportive care, and rehabilitation. Over the past few decades, however, the medical management of stroke has progressed exponentially, beginning with the US Food and Drug Administration (FDA) approval of tissue plasminogen activator (r-TPA, alteplase) in 1996. Intravenous administration of r-TPA within a limited 3-hour window from symptom onset has shown a significant improvement in patient outcome at 3 months and at one year following an acute cerebrovascular event.2 Current stroke guidelines have extended the therapeutic r-TPA administration window to 4.5 hours. The intra-arterial (IA) injection of therapeutic agents was first published nearly 60 years ago, when Sussman and Fitch described the IA treatment of acute carotid occlusion with fibrinolysin injection in 1958.3 It was not until the late 1990’s that the endovascular management of acute stroke experienced exponential progress and development. Recent advances in endovascular techniques have increased the therapeutic window of r-TPA administration and introduced new agents such as reteplase and abciximab. Furthermore, the use of IA devices for clot retrieval and vessel recanalization has revolutionized the neuroendovascular management of acute ischemic stroke.