Management of Acute Ischemic Stroke Due to Large-Vessel Occlusion: JACC Focus Seminar

J Am Coll Cardiol. 2020 Apr 21;75(15):1832-1843. doi: 10.1016/j.jacc.2019.10.034.


Acute ischemic stroke is a severe and life-threatening disease, particularly when caused by a large-vessel occlusion. The only available 2 treatment options are intravenous alteplase and endovascular therapy (mechanical clot removal), both of which are highly time-dependent. Thus, rapid patient transfer, diagnosis, and treatment are crucial, and time-consuming imaging methods and overly selective treatment selection criteria should be avoided. A combined endovascular therapy approach using stent-retrievers and aspiration is the most effective way to achieve fast first-pass complete reperfusion and should thus be used. To diagnose and treat patients as fast as possible, the organization of existing systems of care, and particularly pre-hospital transfer systems, have to be changed. Several different transport models are currently in use because the optimal patient transfer paradigm is highly dependent on local geography and hospital efficiency.

Keywords: CT angiography; acute ischemic stroke; endovascular therapy; guidelines; large-vessel occlusion; systems of care.

Publication types

  • Review

MeSH terms

  • Brain / diagnostic imaging
  • Clinical Decision-Making
  • Endovascular Procedures
  • Fibrinolytic Agents / therapeutic use
  • Humans
  • Intracranial Arterial Diseases / complications
  • Intracranial Arterial Diseases / diagnostic imaging
  • Intracranial Arterial Diseases / therapy*
  • Ischemic Stroke / diagnostic imaging
  • Ischemic Stroke / therapy*
  • Magnetic Resonance Imaging
  • Patient Selection
  • Thrombectomy / instrumentation
  • Thrombectomy / methods
  • Time-to-Treatment
  • Tissue Plasminogen Activator / therapeutic use
  • Tomography, X-Ray Computed
  • Transportation of Patients


  • Fibrinolytic Agents
  • Tissue Plasminogen Activator