Beyond tissue plasminogen activator: mechanical intervention in acute stroke.

Mechanical interventions in acute ischemic stroke promise to provide emergency physicians with tools to treat patients in whom conventional thrombolysis might be ineffective or contraindicated, including most patients with stroke who arrive at the emergency department beyond the 3-hour time window for intravenous tissue plasminogen activator. A systematic MEDLINE literature review was performed. Endovascular interventions currently in early human clinical trials include the use of lasers, ultrasonography, angioplasty, microsnares, and a variety of clot-retrieval devices. Potential advantages of these approaches include more rapid recanalization of occluded vessels, reduced or no exposure to fibrinolytic agents, and a longer treatment window. Early safety trials are promising, with serial improvements in device design to minimize trauma to cerebrovascular endothelium and accelerate vessel recanalization. The purpose of this review is to provide the emergency medicine community with an understanding of these promising and emerging approaches to acute stroke therapy.

[1]  R. Shlansky-Goldberg,et al.  Ultrasound-Assisted Thrombolysis , 1993, Investigative radiology.

[2]  S. Galetta,et al.  Endovascular thrombolysis for symptomatic cerebral venous thrombosis. , 1999, Journal of neurosurgery.

[3]  H. Furuhata,et al.  Can Transcranial Ultrasonication Increase Recanalization Flow With Tissue Plasminogen Activator? , 2001, Stroke.

[4]  T. Mayer,et al.  Treatment of Basilar Artery Embolism With a Mechanical Extraction Device: Necessity of Flow Reversal , 2002, Stroke.

[5]  M. Hennerici,et al.  Low-frequency, low-intensity ultrasound accelerates thrombolysis through the skull. , 1999, Ultrasound in medicine & biology.

[6]  R. Higashida,et al.  Intra-arterial Prourokinase for Acute Ischemic Stroke: The PROACT II Study: A Randomized Controlled Trial , 1999 .

[7]  G. Wikholm.  Mechanical Intracranial Embolectomy , 1998, Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences.

[8]  H. Lutsep,et al.  EPAR Therapy System for Treatment of Acute Stroke: Safety Study Results , 2001 .

[9]  J. Hemphill,et al.  Application of a rheolytic thrombectomy device in the treatment of dural sinus thrombosis: a new technique. , 1999, AJNR. American journal of neuroradiology.

[10]  R. Higashida,et al.  New interventions in cerebrovascular disease: the role of thrombolytic therapy and balloon angioplasty. , 1996, Current opinion in cardiology.

[11]  S. Galetta,et al.  Use of a microsnare to aid direct thrombolytic therapy of dural sinus thrombosis. , 1998, AJR. American journal of roentgenology.

[12]  M. Hennerici,et al.  Acceleration of thrombolysis with ultrasound through the cranium in a flow model. , 2000, Ultrasound in medicine & biology.

[13]  C. Kerber,et al.  Transcatheter snare removal of acute middle cerebral artery thromboembolism: technical case report. , 2000, Neurosurgery.

[14]  T. Mima,et al.  Balloon angioplasty for embolic total occlusion of the middle cerebral artery and ipsilateral carotid stenting in an acute stroke stage. , 1999, AJNR. American journal of neuroradiology.

[15]  R. Higashida,et al.  PROACT: a phase II randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke. PROACT Investigators. Prolyse in Acute Cerebral Thromboembolism. , 1998, Stroke.

[16]  A. Ringer,et al.  Angioplasty of Intracranial Occlusion Resistant to Thrombolysis in Acute Ischemic Stroke , 2001, Neurosurgery.

[17]  Joseph P. Broderick,et al.  Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. , 1995 .

[18]  A M Norbash,et al.  Rheolytic thrombectomy of the occluded internal carotid artery in the setting of acute ischemic stroke. , 2001, AJNR. American journal of neuroradiology.

[19]  J. Saver,et al.  Endovascular treatment of dural sinus thrombosis with rheolytic thrombectomy and intra-arterial thrombolysis. , 2000, Stroke.

[20]  John A. Wilson,et al.  Rapid thrombectomy of superior sagittal sinus and transverse sinus thrombosis with a rheolytic catheter device. , 1999, AJNR. American journal of neuroradiology.

[21]  D. Hovda,et al.  Retrograde transvenous neuroperfusion: a back door treatment for stroke. , 1998, Stroke.

[22]  M. Hennerici,et al.  Potential Use of Therapeutic Ultrasound in Ischemic Stroke Treatment , 2001, Echocardiography.

[23]  H. Lutsep,et al.  Mechanical thrombolysis in acute stroke , 2003 .

[24]  A. Demchuk,et al.  Organised stroke care increases the numbers and the speed with which patients with acute ischemic stroke are thrombolysed , 2002 .

[25]  Gary Duckwiler,et al.  Thrombolytic reversal of acute human cerebral ischemic injury shown by diffusion/perfusion magnetic resonance imaging , 2000, Annals of neurology.