Thrombolysis in Neuromedicine

Abstract

Background: The treatment of patients with cerebral infarction due to vascular stenosis/occlusion includes a range of therapeutic options such as intravenous recombinant tissue plasminogen activator (rtPA) application, thrombocyte aggregation inhibition, anticoagulation, intraarterial thrombolytic medication as well as carotid endarterectomy and endovascular procedures (angioplasty or stenting of extra-and intracranial vessels). Both the drug therapies and endovascular techniques are expected to expand significantly over the next few years. The challenge consists in achieving optimal patient selection for specific therapeutic options. Objective: This position paper is a review and expert consensus document in neuromedicine, concerning the bridging concept in neurovascular diseases. It is the authors' approach to propose guidelines designed to ensure that patients with acute stroke who may be candidates for rapid revascularization have a chance to receive this type of treatment. In this ongoing multidisciplinary discussion all organizational, technical and personnel resources provided by stroke centers and cooperating hospitals should be harmonized and optimized. To ensure that no valuable time is lost and that the available time is used optimally, it may make sense to start systemic application of rtPA for thrombolysis following a diagnosis of nonhemorrhagic brain infarct and confirmation of suitability by means of teleneuromedical systems (TNS) until interventional therapy options or intraarterial local treatment can be initiated. This so-called bridging technique can further increase the success rate of treatment compared to exclusive intraarterial procedures. Outlook and Recommendations: Endovascular therapeutic options are still considered difficult, expensive, and risky, and should be reserved for specialized centers with experienced staff. Therefore, the selection process must be extensive, thorough and precise and patients must be allocated to centers without delay. Through the diffusion of certain techniques, in particular CT-or MRI-guided techniques (CTA, CTP, MRA, DWI, PWI), specific endovascular therapy protocols can be customized to select certain subtypes of stroke. Optimal pathways for specific infarct subtypes, where combined therapy strategies (bridging concepts) are perhaps most attractive, but fairly difficult to establish, should be developed in the near future.