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)


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.


  • 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
  • 2 Bogousslavsky J, Hachinski V C, Boughner D R. Cardiac and arterial lesions in transient ischemic attacks.  Arch Neurol . 1986;  43 223-228
  • 3 Jones T H, Morawetz R B, Crowell R M. Thresholds of focal cerebral ischemia in awake monkeys.  J Neurosurg . 1981;  54 773-782
  • 4 Pulsinelli W A. Selective neuronal vulnerability: morphological and molecular characteristics.  Prog Brain Res . 1985;  63 29-37
  • 5 Zanette E M, Fieschi C, Bozzao L. Comparison of cerebral angiography and transcranial Doppler sonography in acute stroke.  Stroke . 1989;  20 899-903
  • 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
  • 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
  • 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
  • 9 NINDS rt-PA Stroke Group. Tissue plasminogen activator for acute ischemic stroke.  N Engl J Med . 1995;  333 1581-1587
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 16 Derdeyn C P. Physiological neuroimaging: Emerging clinical applications.  JAMA . 2001;  285 3065-3068
  • 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
  • 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
  • 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
  • 20 Schlaug G, Benfield A, Baird A E. The ischemic penumbra: operationally defined by diffusion and perfusion MRI.  Neurology . 1999;  53 1528-1537
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 32 Chalela J A, Katzan I, Liebeskind D S. Safety of intra-arterial thrombolysis in the postoperative period.  Stroke . 2001;  32 1365-1369
  • 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