Therapy of acute ischemic stroke

Authors: MUDr. David Goldemund
Authors‘ workplace: Mezinárodní centrum klinického výzkumu (ICRC) ;  1. neurologická klinika LF MU a FN u sv. Anny, Brno david. goldemund@fnusa. cz
Published in: Kardiol Rev Int Med 2013, 15(1): 26-32


Most of ischemic strokes are caused by acute extra- or intracranial thromboembolic lesion causing artery obstruction. It has been demonstrated that recanalization is the most important modifiable predictor of a good clinical outcome. Reperfusion strategies stated below focus on early reopening of the vessel to reestablish antegrade flow within the penumbra.

ischemic stroke – penumbra – recanalisation – systemic trombosis – intravenous thrombolysis – mechanical recanalisation


1. Smith WS, Sung G, Starkman S et al. MERCI Trial Investigators. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke 2005; 36: 1432–1438.

2. Hacke W, Donnan G, Fieschi C et al. ATLANTIS Trials Investigators; ECASS Trials Investigators; NINDS rt-PA Study Group Investigators. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004; 363: 768–774.

3. Derex L, Nighoghossian N, Hermier M et al. Early detection of cerebral arterial occlusion on magnetic resonance angiography: predictive value of the baseline NIHSS score and impact on neurological outcome. Cerebrovasc Dis 2002; 13: 225–229.

4. Wahlgren N, Ahmed N, Eriksson N et al. Safe Implementation of Thrombolysis in Stroke-MOnitoring STudy Investigators. Multivariable analysis of outcome predictors and adjustment of main outcome results to baseline data profile in randomized controlled trials: Safe Implementation of Thrombolysis in Stroke-MOnitoring STudy (SITS-MOST). Stroke 2008; 39: 3316–3322.

5. Kucinski T, Koch C, Eckert B et al. Collateral circulation is an independent radiological predictor of outcome after thrombolysis in acute ischaemic stroke. Neuroradiology 2003; 45: 11–8.

6. Bang OY, Saver JL, Kim SJ et al. Collateral flow predicts response to endovascular therapy for acute ischemic stroke. Stroke 2011; 42: 693–699.

7. Hill MD, Rowley HA, Adler F et al. PROACT-II Investigators. Selection of acute ischemic stroke pa­tients for intra-arterial thrombolysis with pro-urokinase by using ASPECTS. Stroke 2003; 34: 1925–1931.

8. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med 1995; 333: 1581–1587.

9. Hacke W, Kaste M, Bluhmki E et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359: 1317–1329.

10. Mikulík R, Dufek M. Trombolytická léčba mozkového infarktu-prospektivní sledování souboru pacientů. Čes Slov Neurol Neurochir 2002; 65/98: 328–333.

11. Mikulik R, Ribo M, Hill MD et al. CLOTBUST Investigators. Accuracy of serial National Institutes of Health Stroke Scale scores to identify artery status in acute ischemic stroke. Circulation 2007; 115: 2660–2665.

12. Barreto AD, Alexandrov AV, Lyden P et al. The argatroban and tissue-type plasminogen activator stroke study: final results of a pilot safety study. Stroke 2012; 43: 770–775.

13. Sugg RM, Pary JK, Uchino K et al. Argatroban tPA stroke study: study design and results in the first treated cohort. Arch Neurol 2006; 63: 1057–1062.

14. Furlan A, Higashida R, Wechsler L et al. Intra--arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA 1999; 282: 2003–2011.

15. Ogawa A, Mori E, Minematsu K et al. MELT Japan Study Group. Randomized trial of intraarterial infusion of urokinase within 6 hours of middle cerebral artery stroke: the middle cerebral artery embolism local fibrinolytic intervention trial (MELT) Japan. Stroke 2007; 38: 2633–2639.

16. Smith WS. Safety of mechanical thrombectomy and intravenous tissue plasminogen activator in acute ischemic stroke. Results of the multi Mechanical Embolus Removal in Cerebral Ischemia (MERCI) trial, part I. AJNR Am J Neuroradiol 2006; 27: 1177–1182.

17. Adams HP Jr, del Zoppo G, Alberts MJ et al. American Heart Association; American Stroke Association Stroke Council; Clinical Cardiology Council; Cardiovascular Radiology and Intervention Council; Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007; 38: 1655–1711.

18. Dávalos A, Pereira VM, Chapot R et al. Solitaire Group. Retrospective multicenter study of Solitaire FR for revascularization in the treatment of acute ischemic stroke. Stroke 2012; 43: 2699–2705.

19. Saver JL, Jahan R, Levy EI et al. SWIFT Trialists. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet 2012; 380: 1241–1249.

20. Nogueira RG, Lutsep HL, Gupta R et al. TREVO 2 Trialists. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet 2012; 380: 1231–1240.

21. Penumbra Pivotal Stroke Trial Investigators. The penumbra pivotal stroke trial: safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. Stroke 2009; 40: 2761–2768.

22. Braaten JV, Goss RA, Francis CW. Ultrasound reversibly disaggregates fibrin fibers. Thromb Haemost 1997; 78: 1063–1068.

23. Alexandrov AV, Molina CA, Grotta JC et al. CLOTBUST Investigators. Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke. N Engl J Med 2004; 351: 2170–2178.

24. Molina CA, Barreto AD, Tsivgoulis G et al. Transcranial ultrasound in clinical sonothrombolysis (TUCSON) trial. Ann Neurol 2009; 66: 28–38.

25. Alexandrov AV, Mikulik R, Ribo M et al. A pilot randomized clinical safety study of sonothrombolysis augmentation with ultrasound-activated perflutren-lipid microspheres for acute ischemic stroke. Stroke 2008; 39: 1464–1469.

26. Mikulik R, Bunt L, Hrdlicka D et al. Calling 911 in response to stroke: a nationwide study assessing definitive individual behavior. Stroke 2008; 39: 1844–1849.

27. Ciccone A, Valvassori L, Nichelatti M et al. SYNTHESIS Expansion Investigators. Endovascular Treatment for Acute Ischemic Stroke. N Engl J Med 2013 [Epub ahead of print].

28. Broderick JP, Palesch YY, Demchuk AM et al. Interventional Management of Stroke (IMS) III Investigators. Endovascular Therapy after Intravenous t-PA versus t-PA Alone for Stroke. N Engl J Med 2013 [Epub ahead of print].

Paediatric cardiology Internal medicine Cardiac surgery Cardiology
Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.


Don‘t have an account?  Create new account