Evolution of Reperfusion Therapies for Acute Brain and Acute Myocardial Ischemia

Abstract

Early reperfusion is the most effective therapy for both acute brain and cardiac ischemia. However, the cervicocephalic circulatory bed offers more challenges to recanalization interventions. The historical development of reperfusion interventions has not previously been systematically compared. Medline search identified all multi-arm, controlled trials of coronary revascularization for acute myocardial infarction and multicenter trials of cerebral revascularization for acute ischemic stroke reporting angiographic reperfusion rates. Thirty-seven trials of coronary reperfusion enrolled 10 908 patients from 1983 to 2009, and 10 trials of cerebral reperfusion enrolled 1064 patients from 1992 to 2009. Coronary reperfusion trials included 10 of intravenous fibrinolysis alone, 8 combined intravenous fibrinolysis and percutaneous transluminal coronary angioplasty with or without stenting, 3 intra-arterial fibrinolysis, and 16 percutaneous transluminal coronary angioplasty with or without stenting. Cerebral reperfusion trials included 1 of intravenous fibrinolysis alone, 3 intra-arterial fibrinolysis, 3 endovascular device alone, and 3 of endovascular treatment ± intravenous fibrinolysis. In both circulatory beds, endovascular treatments were more efficacious at achieving reperfusion than peripherally administered fibrinolytics. In the coronary bed, rates of achieved reperfusion began at high levels in the 1980s and improved modestly over the subsequent 3 decades. In the cerebral bed, reperfusion rates began at modest levels in the early 1990s and increased more slowly. Most recently, in 2005 to 2009, cardiac reperfusion rates substantially exceeded cerebral, partial reperfusion 86.1% versus 61.1%, complete reperfusion 78.6% versus 23.4%. Reperfusion therapies developed more slowly and remain less effective for cerebral than cardiac ischemia. Further, cerebral circulation-specific technical advances are required for physicians to become as capable at safely restoring blood flow to the ischemic brain as the ischemic heart.