http://circres.ahajournals.org/content/120/3/541?etoc=
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Abstract
The
treatment of acute ischemic stroke has undergone dramatic changes
recently subsequent to the demonstrated efficacy of intra-arterial (IA)
device-based therapy in multiple trials. The selection of patients for
both intravenous and IA therapy is based on timely imaging with either
computed tomography or magnetic resonance imaging, and if IA therapy is
considered noninvasive, angiography with one of these modalities is
necessary to document a large-vessel occlusion amenable for
intervention. More advanced computed tomography and magnetic resonance
imaging studies are available that can be used to identify a small
ischemic core and ischemic penumbra, and this information will
contribute increasingly in treatment decisions as the therapeutic time
window is lengthened. Intravenous thrombolysis with tissue-type
plasminogen activator remains the mainstay of acute stroke therapy
within the initial 4.5 hours after stroke onset, despite the lack of
Food and Drug Administration approval in the 3- to 4.5-hour time window.
In patients with proximal, large-vessel occlusions, IA device-based
treatment should be initiated in patients with small/moderate-sized
ischemic cores who can be treated within 6 hours of stroke onset. The
organization and implementation of regional stroke care systems will be
needed to treat as many eligible patients as expeditiously as possible.
Novel treatment paradigms can be envisioned combining neuroprotection
with IA device treatment to potentially increase the number of patients
who can be treated despite long transport times and to ameliorate the
consequences of reperfusion injury. Acute stroke treatment has entered a
golden age, and many additional advances can be anticipated.
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