Semin intervent Radiol 2020; 37(02): 109-118
DOI: 10.1055/s-0040-1709152
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Acute Ischemic Stroke: Acute Management and Selection for Endovascular Therapy

Sabeen Dhand
1   Department of Radiology, Lambert Radiology Medical Group at PIH Health, Whittier, California
,
Paul O'Connor
1   Department of Radiology, Lambert Radiology Medical Group at PIH Health, Whittier, California
,
Charles Hughes
2   Department of Neuroscience, University of California Los Angeles, Los Angeles, California
,
Shao-Pow Lin
1   Department of Radiology, Lambert Radiology Medical Group at PIH Health, Whittier, California
› Author Affiliations
Further Information

Publication History

Publication Date:
14 May 2020 (online)

Abstract

Stroke is a medical emergency and expeditious treatment is critical to reducing permanent disability or death. Acute management of patients suffering from acute ischemic stroke (AIS) requires early recognition of symptoms, rapid assessment and stabilization (hyperacute workup), and appropriate selection of patients for reperfusion with intravenous alteplase and/or mechanical thrombectomy. Established stroke protocols which involve both prehospital emergency medical services and in-hospital multidisciplinary stroke teams have been shown to be crucial to reducing the long term, devastating effects of stroke.

 
  • References

  • 1 Centers for Disease Control and Prevention (CDC) Prevalence and most common causes of disability among adults--United States, 2005. MMWR Morb Mortal Wkly Rep 2009; 58 (16) 421-426
  • 2 Mozaffarian D, Benjamin EJ, Go AS. , et al; Writing Group Members; American Heart Association Statistics Committee; Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2016 Update: a report from the American Heart Association. Circulation 2016; 133 (04) e38-e360
  • 3 Heron M. Deaths: leading causes for 2014. Natl Vital Stat Rep 2016; 65 (05) 1-96
  • 4 Powers WJ, Rabinstein AA, Ackerson T. , et al; American Heart Association Stroke Council. 2018 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 2018; 49 (03) e46-e110
  • 5 Zerna C, Thomalla G, Campbell BCV, Rha J-H, Hill MD. Current practice and future directions in the diagnosis and acute treatment of ischaemic stroke. Lancet 2018; 392 (10154): 1247-1256
  • 6 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
  • 7 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
  • 8 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
  • 9 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
  • 10 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
  • 11 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
  • 12 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
  • 13 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
  • 14 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
  • 15 Lin CB, Peterson ED, Smith EE. , et al. Emergency medical service hospital prenotification is associated with improved evaluation and treatment of acute ischemic stroke. Circ Cardiovasc Qual Outcomes 2012; 5 (04) 514-522
  • 16 Gardener H, Pepe PE, Rundek T. , et al. Need to prioritize education of the public regarding stroke symptoms and faster activation of the 9-1-1 system: findings from the Florida-Puerto Rico CReSD Stroke Registry. Prehosp Emerg Care 2019; 23 (04) 439-446
  • 17 Ekundayo OJ, Saver JL, Fonarow GC. , et al. Patterns of emergency medical services use and its association with timely stroke treatment: findings from Get With the Guidelines-Stroke. Circ Cardiovasc Qual Outcomes 2013; 6 (03) 262-269
  • 18 Kansagra AP, Wallace AN, Curfman DR. , et al. Streamlined triage and transfer protocols improve door-to-puncture time for endovascular thrombectomy in acute ischemic stroke. Clin Neurol Neurosurg 2018; 166: 71-75
  • 19 Wang H, Thevathasan A, Dowling R, Bush S, Mitchell P, Yan B. Streamlining workflow for endovascular mechanical thrombectomy: lessons learned from a comprehensive stroke center. J Stroke Cerebrovasc Dis 2017; 26 (08) 1655-1662
  • 20 Sharath KG, Nagesh C. Acute ischemic stroke: a review of imaging, patient selection, and management in the endovascular era. Part I: Initial management and imaging. J Clin Interventional Radiology Isvir 2018; 02 (03) 155-168
  • 21 Target: Stroke Phase II. Available at: https://www.heart.org/-/media/files/professional/quality-improvement/target-stroke/target-stroke-phase-ii/ts_directtoct_ucm_470723.pdf . Accessed October 2, 2019
  • 22 Meretoja A, Strbian D, Mustanoja S, Tatlisumak T, Lindsberg PJ, Kaste M. Reducing in-hospital delay to 20 minutes in stroke thrombolysis. Neurology 2012; 79 (04) 306-313
  • 23 Meretoja A, Weir L, Ugalde M. , et al. Helsinki model cut stroke thrombolysis delays to 25 minutes in Melbourne in only 4 months. Neurology 2013; 81 (12) 1071-1076
  • 24 Ford AL, Williams JA, Spencer M. , et al. Reducing door-to-needle times using Toyota's lean manufacturing principles and value stream analysis. Stroke 2012; 43 (12) 3395-3398
  • 25 Josephson SA, Hills NK, Johnston SC. NIH Stroke Scale reliability in ratings from a large sample of clinicians. Cerebrovasc Dis 2006; 22 (5-6): 389-395
  • 26 Lyden P, Raman R, Liu L, Emr M, Warren M, Marler J. National Institutes of Health Stroke Scale certification is reliable across multiple venues. Stroke 2009; 40 (07) 2507-2511
  • 27 Sharath KG, Nagesh C. Acute ischemic stroke: a review of imaging, patient selection, and management in the endovascular era. Part II: Patient selection, endovascular thrombectomy, and postprocedure management. J Clin Interventional Radiology Isvir 2018; 02 (03) 169-183
  • 28 Aviv RI, Mandelcorn J, Chakraborty S. , et al. Alberta Stroke Program Early CT Scoring of CT perfusion in early stroke visualization and assessment. AJNR Am J Neuroradiol 2007; 28 (10) 1975-1980
  • 29 Puetz V, Sylaja PN, Coutts SB. , et al. Extent of hypoattenuation on CT angiography source images predicts functional outcome in patients with basilar artery occlusion. Stroke 2008; 39 (09) 2485-2490
  • 30 Tei H, Uchiyama S, Usui T, Ohara K. Posterior circulation ASPECTS on diffusion-weighted MRI can be a powerful marker for predicting functional outcome. J Neurol 2010; 257 (05) 767-773
  • 31 Hunter GJ, Hamberg LM, Ponzo JA. , et al. Assessment of cerebral perfusion and arterial anatomy in hyperacute stroke with three-dimensional functional CT: early clinical results. AJNR Am J Neuroradiol 1998; 19 (01) 29-37
  • 32 Lev MH, Segal AZ, Farkas J. , et al. Utility of perfusion-weighted CT imaging in acute middle cerebral artery stroke treated with intra-arterial thrombolysis: prediction of final infarct volume and clinical outcome. Stroke 2001; 32 (09) 2021-2028
  • 33 Heit JJ, Wintermark M. Perfusion computed tomography for the evaluation of acute ischemic stroke: strengths and pitfalls. Stroke 2016; 47 (04) 1153-1158
  • 34 Srinivasan A, Goyal M, Al Azri F, Lum C. State-of-the-art imaging of acute stroke. Radiographics 2006; 26 (01) (Suppl. 01) S75-S95
  • 35 Shankar JJ, Lum C, Sharma M. Whole-brain perfusion imaging with 320-MDCT scanner: reducing radiation dose by increasing sampling interval. AJR Am J Roentgenol 2010; 195 (05) 1183-1186
  • 36 Patel MR, Edelman RR, Warach S. Detection of hyperacute primary intraparenchymal hemorrhage by magnetic resonance imaging. Stroke 1996; 27 (12) 2321-2324
  • 37 Schellinger PD, Bryan RN, Caplan LR. , et al; Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Evidence-based guideline: the role of diffusion and perfusion MRI for the diagnosis of acute ischemic stroke: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2010; 75 (02) 177-185
  • 38 Bang OY, Chung J-W, Son JP. , et al. Multimodal MRI-based triage for acute stroke therapy: challenges and progress. Front Neurol 2018; 9: 586
  • 39 González RG, Copen WA, Schaefer PW. , et al. The Massachusetts General Hospital acute stroke imaging algorithm: an experience and evidence based approach. J Neurointerv Surg 2013; 5 (Suppl. 01) i7-i12
  • 40 Atchaneeyasakul K, Shang T, Haussen D, Ortiz G, Yavagal D. Impact of MRI selection on triage of endovascular therapy in acute ischemic stroke: the MRI in Acute Management of Ischemic Stroke (MIAMIS) Registry. Intervent Neurol 2019; 8 (2–6): 135-143
  • 41 González RG. Clinical MRI of acute ischemic stroke. J Magn Reson Imaging 2012; 36 (02) 259-271
  • 42 Lees KR, Bluhmki E, von Kummer R. , et al; ECASS, ATLANTIS, NINDS and EPITHET rt-PA Study Group. Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 2010; 375 (9727): 1695-1703
  • 43 Emberson J, Lees KR, Lyden P. , et al; Stroke Thrombolysis Trialists' Collaborative Group. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014; 384 (9958): 1929-1935
  • 44 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
  • 45 National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333 (24) 1581-1588
  • 46 Schwamm LH, Wu O, Song SS. , et al; MR WITNESS Investigators. Intravenous thrombolysis in unwitnessed stroke onset: MR WITNESS trial results. Ann Neurol 2018; 83 (05) 980-993
  • 47 Thomalla G, Simonsen CZ, Boutitie F. , et al; WAKE-UP Investigators. MRI-guided thrombolysis for stroke with unknown time of onset. N Engl J Med 2018; 379 (07) 611-622
  • 48 Yamaguchi T, Mori E, Minematsu K. , et al; Japan Alteplase Clinical Trial (J-ACT) Group. Alteplase at 0.6 mg/kg for acute ischemic stroke within 3 hours of onset: Japan Alteplase Clinical Trial (J-ACT). Stroke 2006; 37 (07) 1810-1815
  • 49 Miller DJ, Simpson JR, Silver B. Safety of thrombolysis in acute ischemic stroke: a review of complications, risk factors, and newer technologies. Neurohospitalist 2011; 1 (03) 138-147
  • 50 Tawil SE, Cheripelli B, Huang X. , et al. How many stroke patients might be eligible for mechanical thrombectomy?. Eur Stroke J 2016; 1 (04) 264-271
  • 51 Grossberg JA, Rebello LC, Haussen DC. , et al. Beyond large vessel occlusion strokes: distal occlusion thrombectomy. Stroke 2018; 49 (07) 1662-1668
  • 52 Leslie-Mazwi T, Chandra RV, Baxter BW. , et al; Society of NeuroInterventional Surgery. ELVO: an operational definition. J Neurointerv Surg 2018; 10 (06) 507-509
  • 53 Nogueira RG, Kemmling A, Souza LM. , et al. Clinical diffusion mismatch better discriminates infarct growth than mean transit time-diffusion weighted imaging mismatch in patients with middle cerebral artery-M1 occlusion and limited infarct core. J Neurointerv Surg 2017; 9 (02) 127-130
  • 54 Prosser J, Butcher K, Allport L. , et al. Clinical-diffusion mismatch predicts the putative penumbra with high specificity. Stroke 2005; 36 (08) 1700-1704
  • 55 Ebinger M, Iwanaga T, Prosser JF. , et al; EPITHET Investigators. Clinical-diffusion mismatch and benefit from thrombolysis 3 to 6 hours after acute stroke. Stroke 2009; 40 (07) 2572-2574
  • 56 Luby M, Warach S. Reliability of MR perfusion-weighted and diffusion-weighted imaging mismatch measurement methods. AJNR Am J Neuroradiol 2007; 28 (09) 1674-1678
  • 57 Neumann-Haefelin T, Wittsack H-J, Wenserski F. , et al. Diffusion- and perfusion-weighted MRI. The DWI/PWI mismatch region in acute stroke. Stroke 1999; 30 (08) 1591-1597
  • 58 Chen F, Ni Y-C. Magnetic resonance diffusion-perfusion mismatch in acute ischemic stroke: An update. World J Radiol 2012; 4 (03) 63-74
  • 59 Thomalla G, Cheng B, Ebinger M. , et al; STIR and VISTA Imaging Investigators. DWI-FLAIR mismatch for the identification of patients with acute ischaemic stroke within 4·5 h of symptom onset (PRE-FLAIR): a multicentre observational study. Lancet Neurol 2011; 10 (11) 978-986
  • 60 Mendez B, Requena M, Aires A. , et al. Direct transfer to Angio-Suite to reduce workflow times and increase favorable clinical outcome. Stroke 2018; 49 (11) 2723-2727
  • 61 Ribo M, Boned S, Rubiera M. , et al. Direct transfer to angiosuite to reduce door-to-puncture time in thrombectomy for acute stroke. J Neurointerv Surg 2018; 10 (03) 221-224
  • 62 Brehm A, Tsogkas I, Maier IL. , et al. One-stop management with perfusion for transfer patients with stroke due to a large-vessel occlusion: feasibility and effects on in-hospital times. AJNR Am J Neuroradiol 2019; 40 (08) 1330-1334
  • 63 Boned S, Padroni M, Rubiera M. , et al. Admission CT perfusion may overestimate initial infarct core: the ghost infarct core concept. J Neurointerv Surg 2017; 9 (01) 66-69
  • 64 Martins N, Aires A, Mendez B. , et al. Ghost infarct core and admission computed tomography perfusion: redefining the role of neuroimaging in acute ischemic stroke. Intervent Neurol 2018; 7 (06) 513-521
  • 65 Rebello LC, Bouslama M, Haussen DC. , et al. Endovascular treatment for patients with acute stroke who have a large ischemic core and large mismatch imaging profile. JAMA Neurol 2017; 74 (01) 34-40
  • 66 Manceau PF, Soize S, Gawlitza M. , et al. Is there a benefit of mechanical thrombectomy in patients with large stroke (DWI-ASPECTS ≤ 5)?. Eur J Neurol 2018; 25 (01) 105-110
  • 67 Kakita H, Yoshimura S, Uchida K, Sakai N, Yamagami H, Morimoto T. RESCUE-Japan Registry 2 Investigators. Impact of endovascular therapy in patients with large ischemic core: subanalysis of Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2. Stroke 2019; 50 (04) 901-908
  • 68 Mourand I, Abergel E, Mantilla D. , et al. Favorable revascularization therapy in patients with ASPECTS ≤ 5 on DWI in anterior circulation stroke. J Neurointerv Surg 2018; 10 (01) 5-9