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Treatment of Acute Ischemic Stroke 241

and contraindication in patients with increased bleed- spective studies and subsequently confirmed in a

ing risk,IV rtPA often fails recanalize proximal artery sub analysis of the multicenter randomized clinical
occlusions caused by large clots. These are most dis- trial of endovascular treatment for acute ischemic
abling strokes and strong evidence now exists that stroke in the Netherlands (MR CLEAN) trial. it is be-
these patients should be considered for endovascu- coming increasingly clear that most interventions
lar therapy. can be safely completed using conscious sedation
An appropriately powered large randomized trial will
Mechanical Thrombectomy be necessary to conclusively determine if conscious
sedation should be preferred over general anesthesia
Although endovascular recanalization treatment for
selected patients with severe acute ischemic stroke during endovascular stroke therapy.
has been practiced in many centers for decades, Perhaps the main question is whether the outcomes
the publication of several recent positive trials has observed in the randomized trials can be replicated
showed this therapy to the status of evidence- based in daily practice. To achieve this goal, triaging mech-
treatment for patients with large intracranial artery anisms must be refined and expertise must become
occlusion. more readily available. Organization and implemen-
tation of stroke networks around comprehensive
Candidates for acute Endovascular stroke stroke centres with 24/7 neurointerventional centers
Therapy will have to prove compliance with strict metrics of
efficiency and safety.
• Age 18 years
• NIHSS Score 6 SPECIAL SITUATIONS
• Time from symptom on set to groin puncture Special clinical situations remain for which the ev-
6 hours idence is insufficient to determine the best course
of action until more definite data become available,
• Good prestrike functional status
these cases should be approached considering in-
• Aspects score 6 on baseline CT scan dividual factors and what is known from collective
experience.
• Presence of proximal intracranial artery occlu-
sion
Wake –up Stroke
Exclusion criteria : ASPECTS score <6 in baseline CT Patients whose neurologic deficits are first noticed
scan However, the non-contrast CT scan is not upon their awakening represent a particular chal-
sensitive for the visualization of early ischemia. lenge to the clinician the same applies to those
One of the trials used multiphase CT angiography to with unclear time of onset (such as when the pa-
evaluate collateral vessels, and another required a tient is aphasic and the onset of symptoms was not

CT perfusion showing a limited infarct core and witnessed).These situations constitute formal con-
evidence of penumbra before randomization. Fur- traindications for IV rtPA,but it is widely agreed that
thermore, many patients in trials that did not require some of these patients may benefit from reperfusion
CT perfusion by protocol had this imaging before therapy. When the baseline CT scan shows no evi-
inclusion in the study because that was the prevail- dence of large established infarction it is likely that
ing practice in the enrolling centre ,CT perfusion can advanced imaging with CTperfusion or MR diffusion
provide more reliable assessment of the ischemic re- /perfusion may identify those patients who can be
gion, but its acquisition requires additional time M RI safely treated and can improve after successful re-
diffusion/perfusion is broadly considered the most canalization observational studies support this ap-
accurate method to determine the ischemic core and proach , Which is currently being tested in the DWI or

the extent of the penumbra but this technique is less CTP Assessment with clinical mismatch in the triage
available New software packages promise to accel- of wake up and late presenting strokes undergoing
erate the time required to obtain perfusion imaging neurointervention (DAWN),perfusion imaging selec-
yet at this time, it is unclear if the additional time tion of ischemic Stroke patients for Endovascular
needed to obtain these images is justified .
therapy (POSITIVE), Diffusion and perfusion imaging

A growing body of evidence suggests that interven- evaluation for understanding stroke evolution 3 (DE-

tions performed under conscious sedation have bet- FUSE 3), and A phase lla safety study of intravenous
ter out comes than those performed under general Thrombolysis with Alteplase in MRI- selected patients
anesthesia. This finding was first reported in retro- (MR WITNESS) trials.

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