A New Paradigm Shift in Acute Ischemic Stroke, Large Vessel Occlusions, and Endovascular Therapy

J Emerg Med. 2019 Mar;56(3):258-266. doi: 10.1016/j.jemermed.2018.10.022. Epub 2018 Dec 7.


Background: In the past three years, there have been several major studies published on the use of endovascular therapy (EVT) in large vessel occlusion (LVO) acute ischemic stroke. With multiple publications in such a short amount of time, it is difficult to keep up with the evolving landscape of ischemic stroke therapy.

Objective: This narrative review discusses recent randomized controlled trials evaluating EVT and its effects on acute ischemic stroke management.

Discussion: Ischemic stroke is the most common type of stroke overall, and recanalization is the predominant focus in stroke therapy to improve outcomes. Treatment first focused on systemic thrombolysis for ischemic stroke, followed by studies evaluating the use of thrombolysis with EVT. Early research did not find a benefit to EVT; however, recent studies using current devices and with narrow selection criteria demonstrate significant benefit to EVT in LVOs. In patients with LVOs and perfusion mismatches, reperfusion rates are higher with EVT compared with systemic thrombolysis alone. Recognition of patients with small infarct cores and large areas of ischemic but salvageable brain tissue up to 24 h after symptom onset stresses the need for advanced imaging to recognize the target group.

Conclusions: EVT technology for acute ischemic stroke has now become more efficient, minimizing complications and improving the efficacy of EVT. Several viable interventions for a small subgroup of patients with ischemic stroke up to 24 h after symptoms onset can significantly improve patient outcomes.

Keywords: endovascular; large vessel; occlusion; stroke; thrombolysis.

MeSH terms

  • Arterial Occlusive Diseases / drug therapy
  • Arterial Occlusive Diseases / therapy*
  • Endovascular Procedures / methods
  • Endovascular Procedures / standards*
  • Humans
  • Stroke / drug therapy
  • Stroke / therapy*
  • Thrombolytic Therapy / methods
  • Thrombolytic Therapy / standards
  • Thrombolytic Therapy / trends
  • Treatment Outcome