Acute Ischemic Stroke State of the Art

This transcript has been edited for clarity. Dear colleagues, I am Christoph Diener. I am a neurologist at the University of Duisburg-Essen. In this month's video, I would like to summarize what we learned from randomized studies in the last 4-5 years for the management of acute ischemic stroke. Thrombolysis and ThrombectomyThe most important aspect of stroke treatment is treatment in a stroke unit. This means neurologic examination, immediate imaging, and then control of the most important physiologic parameters like hypertension, blood glucose, temperature, the prevention of aspiration, the prevention of DVT and pulmonary embolism, and early mobilization and early rehabilitation.We also now have highly specific and highly effective treatments. Number one is systemic thrombolysis, either with alteplase or tenecteplase— nowadays, within a time window of up to 24 hours if there is salvageable brain tissue on functional imaging. It's still true that the earlier thrombolysis happens, the more effective it is.It also shows that thrombolysis can be performed in people with high blood pressure and with high glucose and with fever. It has also been shown recently that people with mild strokes do not benefit from thrombolysis; they only have an increased risk for bleeding. The other most important feature is thrombectomy, particularly in people with distal occlusions of the internal carotid artery, the proximal part of the middle cerebral artery, and the posterior circulation. This is highly effective in a time window up to 24 hours, but also the earlier, the better. Now, there is a large amount of discussion whether, for example, people with severe strokes can benefit from mechanical thrombectomy, and we have now six randomized trials that clearly show that thrombectomy is also effective in these patients and does not increase the risk for bleeding.Now, it is controversial whether thrombectomy works in people with occlusions of the middle and distal part of the middle cerebral artery. We have positive trials and we have negative trials, so we have to wait for further trials to make a final decision. Also, there is a large amount of discussion whether systemic thrombolysis prior to thrombectomy improves outcome. There is a strong trend for this. Now, this is particularly important for people who are transferred to a stroke center for thrombectomy. In these patients, systemic thrombolysis with tenecteplase should be started before the patient is sent to the stroke center. Now, the other important feature is whether it is useful to use IV thrombolysis after mechanical thrombectomy, particularly in people who don't really benefit from thrombectomy. Again, here we have controversial randomized trials, some with positive outcomes and some with negative outcomes. We have to see whether this can be resolved in future studies. GP IIb/IIa Inhibitor and Factor XIa Inhibitors Another aspect is the use of tirofiban, a highly effective short-acting antiplatelet therapy in patients who do not benefit from thrombolysis. There is one trial that showed a small benefit, which was negative for most secondary endpoints. Again, this is not resolved. What is new in early secondary prevention in future is the use of asundexian, a factor XIa inhibitor, in addition to aspirin, or aspirin and clopidogrel. As soon as this drug is approved, this will be introduced into secondary prevention. We have a large amount of new information, and I would like to refer you to the recently published guidelines of the American Stroke Association and the American Heart Association, published in Stroke.Dear colleagues, I am Christoph Diener, from the Medical Faculty at University of Duisburg-Essen. This was a short review on what has happened in the last few years in the management of acute ischemic stroke. Thank you very much for listening and watching.