A revolution in stroke therapy: reperfusion therapy effective even if late

Abstract Arterial recanalization procedures after ischaemic stroke, are now well-established treatments, within 5 h for systemic thrombolysis, and 6 h for the endovascular treatment. Ischaemic stroke with uncertain time of symptoms onset, account for 14–27% of the cases, the vast majority of which occur just after waking up, thus it is impossible to derive an exact timeline. Accordingly, these patients are frequently not eligible for acute treatment. The results of three recent trials, DAWN, DEFUSE 3, and WAKE-UP, provided the basis for a revolution in the selection of patients eligible for late revascularization, and revealed an increase in the rate of functional independence for these patients at 90 days (mRS 0–2). Advanced neuroimaging techniques have been shown to be of utmost importance in the definition of the cerebral tissue window. A wider application of these imaging techniques and standardization of the parameters of images acquisition would provide for a significant advancement in the management of ischaemic stroke in the emergency setting.

[1]  M. Kaste,et al.  Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. , 2008, The New England journal of medicine.

[2]  Keith Muir,et al.  Thrombolysis with alteplase 3–4·5 h after acute ischaemic stroke (SITS-ISTR): an observational study , 2008, The Lancet.

[3]  Hester F. Lingsma,et al.  A randomized trial of intraarterial treatment for acute ischemic stroke. , 2015, The New England journal of medicine.

[4]  M. Krause,et al.  Endovascular therapy for ischemic stroke with perfusion-imaging selection. , 2015, The New England journal of medicine.

[5]  A. Demchuk,et al.  Thrombectomy within 8 hours after symptom onset in ischemic stroke. , 2015, The New England journal of medicine.

[6]  Eric E. Smith,et al.  Randomized assessment of rapid endovascular treatment of ischemic stroke. , 2015, The New England journal of medicine.

[7]  H. Diener,et al.  Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. , 2015, The New England journal of medicine.

[8]  Roland Bammer,et al.  Ischemic core and hypoperfusion volumes predict infarct size in SWIFT PRIME , 2016, Annals of neurology.

[9]  Adnan H Siddiqui,et al.  Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis. , 2016, JAMA.

[10]  T. Jovin,et al.  Fast Versus Slow Progressors of Infarct Growth in Large Vessel Occlusion Stroke: Clinical and Research Implications , 2017, Stroke.

[11]  Heather B. Roesly.  Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging , 2018, The Journal of Emergency Medicine.

[12]  C. Gerloff,et al.  MRI‐Guided Thrombolysis for Stroke with Unknown Time of Onset , 2018, The New England journal of medicine.

[13]  M. Chen,et al.  Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct , 2018, The New England journal of medicine.

[14]  A. Demchuk,et al.  Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging , 2018, The New England journal of medicine.

[15]  R. Sacco,et al.  Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. , 2019, Stroke.