Improving Reperfusion Therapies in the Era of Mechanical Thrombectomy

Abstract

Recent positive clinical trials using mechanical thrombectomy proved that endovascular recanalization is an effective treatment for patients with acute stroke secondary to large vessel occlusions. The trials offer definite evidence that in acute ischemia recanalization is a powerful predictor of good outcome. However, even in the era of rapid and effective recanalization using endovascular approaches, the percentage of patients with good outcomes varies between 33% and 71%. In addition, the number of patients who are eligible for endovascular thrombectomy is small and usually based on having salvageable tissue on imaging. There is therefore room for improvement to both enhance the effectiveness of current practice and expand treatment to a larger subset of stroke patients. In this review, we highlight some of the most promising approaches to improve endovascular therapy by combining with strategies to enhance collateral perfusion and vascular protection.

Blood–Brain Barrier Disruption, Vascular Impairment, and Ischemia/Reperfusion Damage in Diabetic Stroke

“…However, this treatment is challenged by practicality because of its narrow treatment window (3–4.5 hours after stroke onset). Recent advances in stroke treatments have enabled rapid and effective recanalization using endovascular approaches such as mechanical thrombectomy, and patients with salvageable tissues benefit from improved outcomes 88. However, only a small population of stroke patients is eligible for acute endovascular intervention 88.…”

“…Recent advances in stroke treatments have enabled rapid and effective recanalization using endovascular approaches such as mechanical thrombectomy, and patients with salvageable tissues benefit from improved outcomes 88. However, only a small population of stroke patients is eligible for acute endovascular intervention 88. Following I/R, a brief episode of hyperperfusion is followed by secondary hypoperfusion during which there is additional injury to the brain 89.…”

Translational Stroke Research Opportunities and a Strategy to Develop Effective Cytoprotection

“…And (MR. CLEAN) [7], Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) [8], Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours (REVASCAT) [9], Solitaire With the Intention For Thrombectomy as PRIMary Endovascular Treatment (SWIFT PRIME) Trial [10] and Extending the Time for Thrombolysis in Emergency Neurological Deficits-Intra-Arterial (EXTEND-IA) [11]). The immediate goal of the stroke community is to continue to develop novel forms of cytoprotective therapy to further enhance the benefit of embolectomy and thrombolysis [12][13][14]. By demonstrating additional clinical benefit with a cytoprotective compound in standardized translational stroke models, we may be able to initiate clinical trials in patients undergoing thrombolytic/endovascular procedures [12,15].…”

To Improve Translational Research in Subarachnoid Hemorrhage

“…In addition, academic-industry collaborations are needed to overcome the translational stroke research roadblock, such as the advent of the multicenter preclinical trial concept [20]. Although the guidelines stem from the need to assess neuroprotection for acute ischemic stroke, they have been applied to the evaluation of other treatments, interventions, and fields of neuroscience with or without a modification [21][22][23][24][25][26].…”