Acute Reperfusion Therapies for Acute Ischemic Stroke

Abstract

The field of acute stroke treatment has made tremendous progress in reducing the overall burden of disability. Understanding the pathophysiology of acute ischemic injury, neuroimaging to quantify the extent of penumbra and infarction, and acute stroke reperfusion therapies have together contributed to these advancements. In this review we highlight advancements in reperfusion therapies for acute ischemic stroke.

Clinical Outcomes of Extracranial Carotid Artery-Related Stroke Eligible for Mechanical Reperfusion on Top of Per-Guidelines Thrombolytic Therapy: Analysis from a 6-Month Consecutive Patient Sample in 2 Centers

“…In our cohort, all eligible patients (33.3%) received thrombolysis. This, however, was largely ineffective (note the lack of IVT clinical efficacy, major cerebral tissue loss on control CT scans in EMR-eligible patients who received IVT but no EMR; Figure 1 ), consistent with prior reports of very poor efficacy of IVT in recanalizing CA [ 9 – 11 ]. Data from the present study reinforce the guidelines’ position that any “waiting” for a clinical effect of IVT (which is typically achieved in less than 10% of AIS-CAs) must no longer be a part of any contemporary clinical practice [ 12 ].…”

“…Strokes of carotid bifurcation origin constitute at least 20% of ischemic strokes [ 1 , 6 ]; some of those present with a co-existing occlusion of the intracranial vessel(s) (tandem lesions) [ 7 , 8 ]. Acute ischemic stroke of extracranial carotid artery origin (AIS-CA) has an unfavorable clinical prognosis due to the large volume of affected brain tissue and the typically large thrombus load, with recanalization rates below 10% using systemic intravenous thrombolysis (IVT) [ 9 – 11 ]. IVT is an established part of stroke reperfusion therapy that, in the setting of large vessel occlusions (LVO), should be combined with mechanical reperfusion [ 10 – 16 ].…”

“…Recent technological advances allow thrombus extraction using aspiration and/or stentrievers, with a high recanalization rate [ 11 , 17 ], from the extracranial internal CA (similarly to the intracranial segments of internal CA [ 24 ]), as well as a full reconstruction of the CA lumen with lesion sequestration [ 25 ]. However, data on the implementation of these new technologies in acute stroke are scarce [ 24 ].…”

Brain’s Energy After Stroke: From a Cellular Perspective Toward Behavior

“…A paradigmatic case is a stroke, where a drop in blood flow by an arterial conflict (thrombosis, embolism, or hemorrhage) provokes a deterioration of the functioning of brain regions dependent on such a source of energy. The extreme energy dependence of brain tissue is manifested by the fact that initial neurologic impairments could be reverted if reperfusion strategies restitute the blood flow ( Imran et al, 2021 ). This brain pathophysiology supports current theoretical proposals that highlight the role of energy homeostasis as a constraint for neuronal processes at the molecular, network, and behavioral levels ( Vergara et al, 2019 ).…”

Fatty Acid-Binding Proteins: Their Roles in Ischemic Stroke and Potential as Drug Targets

“…Moreover, approximately 85% of strokes are ischemic strokes caused by vascular occlusion, of which approximately 75% are attributable to embolism, the most common cause of regional cerebral blood flow obstruction [ 3 ]. Although early blood flow restoration mediated via thrombolysis or mechanical thrombectomy is the preferred treatment to limit post-stroke brain damage [ 4 , 5 ], brain tissue damage is caused not only by ischemic injury, but also by oxidative stress and inflammation following reperfusion, which are sources of additional damage to the cerebral microcirculation and adjacent brain tissue, a condition known as cerebral ischemia/reperfusion injury (CI/RI) [ 3 , 6 ]. In the area of ischemic lesion, all cells of the neurovascular unit are injured, resulting in a series of complex ischemic cascade reactions [ 7 ].…”