Outcome Improvement in Acute Stroke Revascularization Procedures

Abstract

See related article, pages 695–699. Mechanical thrombectomy, intra-arterial thrombolysis, and intracranial stenting procedures are increasingly used in patients with symptoms of acute brain ischemia and usually within the first 12 hours after the beginning of symptoms. The rational underlying these acute interventions is to expand the therapeutic time window, because the number of patients presenting within the first 3 hours remains limited.1 Despite more than a decade of experience, the efficacy of these interventions is not firmly established, and they are associated with a substantial risk of complications, such as brain infarction or hemorrhage, arterial dissection, and death. The risk of procedural complications ranges between 5% and 29%, with an average stroke and death rate of ≈10% in recent series.2–7 In an effort to reduce complications, investigators have aimed at identifying clinical risk factors associated with adverse outcomes2 and have also tried to improve patient selection. Patients with posterior circulation arterial stenoses2 or with a blood glucose level >200 mg/dL6 have a relatively high risk. Procedures performed at medical centers with low volumes or by interventionalists with limited experience are associated with a higher risk of complications. Furthermore, patients with large mismatches between diffusion and perfusion on brain neuroimaging studies are more likely to benefit from the procedures and are better candidates.8 The introduction of these variables in patient selection may improve results. The clinical approach presented in the preceeding paragraph has the advantage …