Recent developments and innovations in emergency department for the management and treatment of acute ischemic stroke

https://doi.org/10.53730/ijhs.v6nS10.15131

Authors

  • Omar Hussain Alsomali KSA, National Guard Health Affairs
  • Eissa Hamed Alsulami KSA, National Guard Health Affairs
  • Munifah Afit Alshammari KSA, National Guard Health Affairs
  • Fahad Mohammed Altayawi KSA, National Guard Health Affairs
  • Abdulelah Dawas Alonezi KSA, National Guard Health Affairs
  • Abdullah Hashem Kabi KSA, National Guard Health Affairs
  • Adel Zayed Almutairi KSA, National Guard Health Affairs
  • Fahad Ghazi Almutairi KSA, National Guard Health Affairs
  • Sulaiman Salem Alhuwayrini KSA, National Guard Health Affairs
  • ‏Hamad Marshud Alotaibi KSA, National Guard Health Affairs
  • ‏Bander Khalid Baurasien KSA, National Guard Health Affairs
  • ‏Hind Saad Alareefi KSA, National Guard Health Affairs

Keywords:

Acute ischemic stroke, intravenous thrombolysis, mechanical thrombectomy, neuroprotection, imaging techniques, tenecteplase, thrombolytic agents

Abstract

Background: In the past five years, substantial advancements have occurred in the management and treatment of acute ischemic stroke. The primary goal remains to preserve ischemic tissue and enhance clinical outcomes. The pathophysiology of ischemic stroke involves a complex cascade of events following the obstruction of blood vessels by thrombi or emboli, impacting neurons and other cellular components in the neurovascular unit. Recent advancements in imaging technologies, including CT perfusion and MRI techniques, have enabled better assessment of ischemic progression and treatment decision-making. Aim: The aim of this review is to summarize recent developments and innovations in the management and treatment of acute ischemic stroke, focusing on advancements in imaging techniques, therapeutic strategies, and emerging thrombolytic agents. Methods: The review synthesizes recent literature on acute ischemic stroke therapies, including intravenous thrombolysis, mechanical thrombectomy, and neuroprotection strategies. It evaluates new imaging modalities and their role in treatment planning. The review also examines recent clinical trials and studies on novel thrombolytic agents. Results: Recent imaging advancements, such as CT perfusion and MRI diffusion/perfusion imaging, have improved the assessment of ischemic tissue and infarction progression. 

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References

Chamorro, Á, Lo, EH, Renú, A, van Leyen, K, Lyden, PD. The future of neuroprotection in stroke. J Neurol Neurosurg Psychiatry. 2021;92:129–135. doi: 10.1136/jnnp-2020-324283 DOI: https://doi.org/10.1136/jnnp-2020-324283

Catanese, L, Tarsia, J, Fisher, M. Acute ischemic stroke therapy overview. Circ Res. 2017;120:541–558. doi: 10.1161/CIRCRESAHA.116.309278 DOI: https://doi.org/10.1161/CIRCRESAHA.116.309278

Fisher, M. Characterizing the target of acute stroke therapy. Stroke. 1997;28:866–872. doi: 10.1161/01.str.28.4.866 DOI: https://doi.org/10.1161/01.STR.28.4.866

Lyden, PD. Cerebroprotection for acute ischemic stroke: looking ahead. Stroke. 2021;52:3033–3044. doi: 10.1161/STROKEAHA.121.032241 DOI: https://doi.org/10.1161/STROKEAHA.121.032241

Moskowitz, MA, Lo, EH, Iadecola, C. The science of stroke: mechanisms in search of treatments. Neuron. 2010;67:181–198. doi: 10.1016/j.neuron.2010.07.002 DOI: https://doi.org/10.1016/j.neuron.2010.07.002

Ospel, JM, Hill, MD, Kappelhof, M, Demchuk, AM, Menon, BK, Mayank, A, Dowlatshahi, D, Frei, D, Rempel, JL, Baxter, B, et al. Which acute ischemic stroke patients are fast progressors?: Results from the ESCAPE trial control arm. Stroke. 2021;52:1847–1850. doi: 10.1161/STROKEAHA.120.032950 DOI: https://doi.org/10.1161/STROKEAHA.120.032950

Demeestere, J, Wouters, A, Christensen, S, Lemmens, R, Lansberg, MG. Review of perfusion imaging in acute ischemic stroke: from time to tissue. Stroke. 2020;51:1017–1024. doi: 10.1161/STROKEAHA.119.028337 DOI: https://doi.org/10.1161/STROKEAHA.119.028337

Tsivgoulis, G, Kargiotis, O, Alexandrov, AV. Intravenous thrombolysis for acute ischemic stroke: a bridge between two centuries. Expert Rev Neurother. 2017;17:819–837. doi: 10.1080/14737175.2017.1347039 DOI: https://doi.org/10.1080/14737175.2017.1347039

Goyal, M, Menon, BK, van Zwam, WH, Dippel, DW, Mitchell, PJ, Demchuk, AM, Dávalos, A, Majoie, CB, van der Lugt, A, de Miquel, MA, et al; HERMES collaborators. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387:1723–1731. doi: 10.1016/S0140-6736(16)00163-X DOI: https://doi.org/10.1016/S0140-6736(16)00163-X

Savitz, SI, Baron, JC, Yenari, MA, Sanossian, N, Fisher, M. Reconsidering neuroprotection in the reperfusion era. Stroke. 2017;48:3413–3419. doi: 10.1161/STROKEAHA.117.017283 DOI: https://doi.org/10.1161/STROKEAHA.117.017283

Savitz, SI, Baron, JC, Fisher, M; STAIR X Consortium. Stroke treatment academic industry Roundtable X: brain cytoprotection therapies in the reperfusion era. Stroke. 2019;50:1026–1031. doi: 10.1161/STROKEAHA.118.023927 DOI: https://doi.org/10.1161/STROKEAHA.118.023927

Saver, JL. Time is brain–quantified. Stroke. 2006;37:263–266. doi: 10.1161/01.STR.0000196957.55928.ab DOI: https://doi.org/10.1161/01.STR.0000196957.55928.ab

Meyran, D, Cassan, P, Avau, B, Singletary, E, Zideman, DA. Stroke recognition for first aid providers: a systematic review and meta-analysis. Cureus. 2020;12:e11386. doi: 10.7759/cureus.11386 DOI: https://doi.org/10.7759/cureus.11386

Nguyen, TTM, van den Wijngaard, IR, Bosch, J, van Belle, E, van Zwet, EW, Dofferhoff-Vermeulen, T, Duijndam, D, Koster, GT, de Schryver, ELLM, Kloos, LMH, et al. Comparison of prehospital scales for predicting large anterior vessel occlusion in the ambulance setting. JAMA Neurol. 2021;78:157–164. doi: 10.1001/jamaneurol.2020.4418 DOI: https://doi.org/10.1001/jamaneurol.2020.4418

Desai, SM, Leslie-Mazwi, TM, Hirsch, JA, Jadhav, AP. Optimal transfer paradigm for emergent large vessel occlusion strokes: recognition to recanalization in the RACECAT trial. J Neurointerv Surg. 2021;13:97–99. doi: 10.1136/neurintsurg-2020-017227 DOI: https://doi.org/10.1136/neurintsurg-2020-017227

American Heart Association. Severity-Based stroke triage algorithm for EMS 2020. https://www.heart.org/missionlifelinestroke. Accessed Jan 15, 2022.

Demaerschalk, BM, Raman, R, Ernstrom, K, Meyer, BC. Efficacy of telemedicine for stroke: pooled analysis of the Stroke Team Remote Evaluation Using a Digital Observation Camera (STRokE DOC) and STRokE DOC Arizona telestroke trials. Telemed J E Health. 2012;18:230–237. doi: 10.1089/tmj.2011.0116 DOI: https://doi.org/10.1089/tmj.2011.0116

Ebinger, M, Siegerink, B, Kunz, A, Wendt, M, Weber, JE, Schwabauer, E, Geisler, F, Freitag, E, Lange, J, Behrens, J, et al; Berlin_PRehospital Or Usual Delivery in stroke care (B_PROUD) study group. Association between dispatch of mobile stroke units and functional outcomes among patients with acute ischemic stroke in Berlin. JAMA. 2021;325:454–466. doi: 10.1001/jama.2020.26345 DOI: https://doi.org/10.1001/jama.2020.26345

Grotta, JC, Yamal, JM, Parker, SA, Rajan, SS, Gonzales, NR, Jones, WJ, Alexandrov, AW, Navi, BB, Nour, M, Spokoyny, I, et al. Prospective, multicenter, controlled trial of mobile stroke units. N Engl J Med. 2021;385:971–981. doi: 10.1056/NEJMoa2103879 DOI: https://doi.org/10.1056/NEJMoa2103879

Thomalla, G, Simonsen, CZ, Boutitie, F, Andersen, G, Berthezene, Y, Cheng, B, Cheripelli, B, Cho, TH, Fazekas, F, Fiehler, J, et al; WAKE-UP Investigators. MRI-Guided thrombolysis for stroke with unknown time of onset. N Engl J Med. 2018;379:611–622. doi: 10.1056/NEJMoa1804355 DOI: https://doi.org/10.1056/NEJMoa1804355

Thomalla, G, Cheng, B, Ebinger, M, Hao, Q, Tourdias, T, Wu, O, Kim, JS, Breuer, L, Singer, OC, Warach, S, et al; STIR and VISTA Imaging Investigators. DWI-FLAIR mismatch for the identification of patients with acute ischaemic stroke within 4·5 h of symptom onset (PRE-FLAIR): a multicentre observational study. Lancet Neurol. 2011;10:978–986. doi: 10.1016/S1474-4422(11)70192-2 DOI: https://doi.org/10.1016/S1474-4422(11)70192-2

Koga, M, Yamamoto, H, Inoue, M, Asakura, K, Aoki, J, Hamasaki, T, Kanzawa, T, Kondo, R, Ohtaki, M, Itabashi, R, et al; THAWS Trial Investigators. Thrombolysis with Alteplase at 0.6 mg/kg for stroke with unknown time of onset: a randomized controlled trial. Stroke. 2020;51:1530–1538. doi: 10.1161/STROKEAHA.119.028127 DOI: https://doi.org/10.1161/STROKEAHA.119.028127

Ma, H, Campbell, BCV, Parsons, MW, Churilov, L, Levi, CR, Hsu, C, Kleinig, TJ, Wijeratne, T, Curtze, S, Dewey, HM, et al; EXTEND Investigators. Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke. N Engl J Med. 2019;380:1795–1803. doi: 10.1056/NEJMoa1813046 DOI: https://doi.org/10.1056/NEJMoa1813046

Ringleb, P, Bendszus, M, Bluhmki, E, Donnan, G, Eschenfelder, C, Fatar, M, Kessler, C, Molina, C, Leys, D, Muddegowda, G, et al; ECASS-4 study group. Extending the time window for intravenous thrombolysis in acute ischemic stroke using magnetic resonance imaging-based patient selection. Int J Stroke. 2019;14:483–490. doi: 10.1177/1747493019840938 DOI: https://doi.org/10.1177/1747493019840938

Campbell, BCV, Ma, H, Ringleb, PA, Parsons, MW, Churilov, L, Bendszus, M, Levi, CR, Hsu, C, Kleinig, TJ, Fatar, M, et al; EXTEND, ECASS-4, and EPITHET Investigators. Extending thrombolysis to 4·5-9 h and wake-up stroke using perfusion imaging: a systematic review and meta-analysis of individual patient data. Lancet. 2019;394:139–147. doi: 10.1016/S0140-6736(19)31053-0 DOI: https://doi.org/10.1016/S0140-6736(19)31053-0

Thomalla, G, Boutitie, F, Ma, H, Koga, M, Ringleb, P, Schwamm, LH, Wu, O, Bendszus, M, Bladin, CF, Campbell, BCV, et al; Evaluation of unknown Onset Stroke thrombolysis trials (EOS) investigators. Intravenous alteplase for stroke with unknown time of onset guided by advanced imaging: systematic review and meta-analysis of individual patient data. Lancet. 2020;396:1574–1584. doi: 10.1016/S0140-6736(20)32163-2 DOI: https://doi.org/10.1016/S0140-6736(20)32163-2

Tanswell, P, Modi, N, Combs, D, Danays, T. Pharmacokinetics and pharmacodynamics of tenecteplase in fibrinolytic therapy of acute myocardial infarction. Clin Pharmacokinet. 2002;41:1229–1245. doi: 10.2165/00003088-200241150-00001 DOI: https://doi.org/10.2165/00003088-200241150-00001

Coutts, SB, Dubuc, V, Mandzia, J, Kenney, C, Demchuk, AM, Smith, EE, Subramaniam, S, Goyal, M, Patil, S, Menon, BK, et al; TEMPO-1 Investigators. Tenecteplase-tissue-type plasminogen activator evaluation for minor ischemic stroke with proven occlusion. Stroke. 2015;46:769–774. doi: 10.1161/STROKEAHA.114.008504 DOI: https://doi.org/10.1161/STROKEAHA.114.008504

Huang, X, Cheripelli, BK, Lloyd, SM, Kalladka, D, Moreton, FC, Siddiqui, A, Ford, I, Muir, KW. Alteplase versus tenecteplase for thrombolysis after ischaemic stroke (ATTEST): a phase 2, randomised, open-label, blinded endpoint study. Lancet Neurol. 2015;14:368–376. doi: 10.1016/S1474-4422(15)70017-7 DOI: https://doi.org/10.1016/S1474-4422(15)70017-7

Logallo, N, Novotny, V, Assmus, J, Kvistad, CE, Alteheld, L, Rønning, OM, Thommessen, B, Amthor, KF, Ihle-Hansen, H, Kurz, M, et al. Tenecteplase versus alteplase for management of acute ischaemic stroke (NOR-TEST): a phase 3, randomised, open-label, blinded endpoint trial. Lancet Neurol. 2017;16:781–788. doi: 10.1016/S1474-4422(17)30253-3 DOI: https://doi.org/10.1016/S1474-4422(17)30253-3

Campbell, BCV, Mitchell, PJ, Churilov, L, Yassi, N, Kleinig, TJ, Dowling, RJ, Yan, B, Bush, SJ, Thijs, V, Scroop, R, et al; EXTEND-IA TNK Part 2 investigators. Effect of intravenous tenecteplase dose on cerebral reperfusion before thrombectomy in patients with large vessel occlusion ischemic stroke: the EXTEND-IA TNK Part 2 randomized clinical trial. JAMA. 2020;323:1257–1265. doi: 10.1001/jama.2020.1511 DOI: https://doi.org/10.1001/jama.2020.1511

Haley, EC, Jr, Lyden, PD, Johnston, KC, Hemmen, TM; TNK in Stroke Investigators. A pilot dose-escalation safety study of tenecteplase in acute ischemic stroke. Stroke. 2005;36:607–612. doi: 10.1161/01.STR.0000154872.73240.e9 DOI: https://doi.org/10.1161/01.STR.0000154872.73240.e9

Parsons, M, Spratt, N, Bivard, A, Campbell, B, Chung, K, Miteff, F, O’Brien, B, Bladin, C, McElduff, P, Allen, C, et al. A randomized trial of tenecteplase versus alteplase for acute ischemic stroke. N Engl J Med. 2012;366:1099–1107. doi: 10.1056/NEJMoa1109842 DOI: https://doi.org/10.1056/NEJMoa1109842

Bivard, A, Huang, X, Levi, CR, Spratt, N, Campbell, BCV, Cheripelli, BK, Kalladka, D, Moreton, FC, Ford, I, Bladin, CF, et al. Tenecteplase in ischemic stroke offers improved recanalization: Analysis of 2 trials. Neurology. 2017;89:62–67. doi: 10.1212/WNL.0000000000004062 DOI: https://doi.org/10.1212/WNL.0000000000004062

Bivard, A, Huang, X, McElduff, P, Levi, CR, Campbell, BC, Cheripelli, BK, Kalladka, D, Moreton, FC, Ford, I, Bladin, CF, et al. Impact of computed tomography perfusion imaging on the response to tenecteplase in ischemic stroke: analysis of 2 randomized controlled trials. Circulation. 2017;135:440–448. doi: 10.1161/CIRCULATIONAHA.116.022582 DOI: https://doi.org/10.1161/CIRCULATIONAHA.116.022582

Campbell, BCV, Mitchell, PJ, Churilov, L, Yassi, N, Kleinig, TJ, Dowling, RJ, Yan, B, Bush, SJ, Dewey, HM, Thijs, V, et al; EXTEND-IA TNK Investigators. Tenecteplase versus alteplase before thrombectomy for ischemic stroke. N Engl J Med. 2018;378:1573–1582. doi: 10.1056/NEJMoa1716405 DOI: https://doi.org/10.1056/NEJMoa1716405

Katsanos, AH, Safouris, A, Sarraj, A, Magoufis, G, Leker, RR, Khatri, P, Cordonnier, C, Leys, D, Shoamanesh, A, Ahmed, N, et al. Intravenous thrombolysis with tenecteplase in patients with large vessel occlusions: systematic review and meta-analysis. Stroke. 2021;52:308–312. doi: 10.1161/STROKEAHA.120.030220 DOI: https://doi.org/10.1161/STROKEAHA.120.030220

Powers, WJ, Rabinstein, AA, Ackerson, T, Adeoye, OM, Bambakidis, NC, Becker, K, Biller, J, Brown, M, Demaerschalk, BM, Hoh, B, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50:e344–e418. doi: 10.1161/STR.0000000000000211 DOI: https://doi.org/10.1161/STR.0000000000000211

Collen, D. Staphylokinase: a potent, uniquely fibrin-selective thrombolytic agent. Nat Med. 1998;4:279–284. doi: 10.1038/nm0398-279 DOI: https://doi.org/10.1038/nm0398-279

Gusev, EI, Martynov, MY, Nikonov, AA, Shamalov, NA, Semenov, MP, Gerasimets, EA, Yarovaya, EB, Semenov, AM, Archakov, AI, Markin, SS; FRIDA Study Group. Non-immunogenic recombinant staphylokinase versus alteplase for patients with acute ischaemic stroke 4·5 h after symptom onset in Russia (FRIDA): a randomised, open label, multicentre, parallel-group, non-inferiority trial. Lancet Neurol. 2021;20:721–728. doi: 10.1016/S1474-4422(21)00210-6 DOI: https://doi.org/10.1016/S1474-4422(21)00210-6

Rothwell, PM, Buchan, AM. A new thrombolytic drug for acute ischaemic stroke. Lancet Neurol. 2021;20:687–689. doi: 10.1016/S1474-4422(21)00256-8 DOI: https://doi.org/10.1016/S1474-4422(21)00256-8

Khatri, P, Kleindorfer, DO, Devlin, T, Sawyer, RN, Jr, Starr, M, Mejilla, J, Broderick, J, Chatterjee, A, Jauch, EC, Levine, SR, et al; PRISMS Investigators. Effect of alteplase vs aspirin on functional outcome for patients with acute ischemic stroke and minor nondisabling neurologic deficits: the PRISMS randomized clinical trial. JAMA. 2018;320:156–166. doi: 10.1001/jama.2018.8496 DOI: https://doi.org/10.1001/jama.2018.8496

Berge, E, Whiteley, W, Audebert, H, De Marchis, GM, Fonseca, AC, Padiglioni, C, de la Ossa, NP, Strbian, D, Tsivgoulis, G, Turc, G. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J. 2021;6:I–LXII. doi: 10.1177/2396987321989865 DOI: https://doi.org/10.1177/2396987321989865

Kleindorfer, DO, Towfighi, A, Chaturvedi, S, Cockroft, KM, Gutierrez, J, Lombardi-Hill, D, Kamel, H, Kernan, WN, Kittner, SJ, Leira, EC, et al. 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline from the American Heart Association/American Stroke Association. Stroke. 2021;52:e364–e467. doi: 10.1161/STR.0000000000000375 DOI: https://doi.org/10.1161/STR.0000000000000375

Berkhemer, OA, Fransen, PS, Beumer, D, van den Berg, LA, Lingsma, HF, Yoo, AJ, Schonewille, WJ, Vos, JA, Nederkoorn, PJ, Wermer, MJ, et al; MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11–20. doi: 10.1056/NEJMoa1411587 DOI: https://doi.org/10.1056/NEJMoa1411587

Goyal, M, Demchuk, AM, Menon, BK, Eesa, M, Rempel, JL, Thornton, J, Roy, D, Jovin, TG, Willinsky, RA, Sapkota, BL, et al; ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019–1030. doi: 10.1056/NEJMoa1414905 DOI: https://doi.org/10.1056/NEJMoa1414905

Jovin, TG, Chamorro, A, Cobo, E, de Miquel, MA, Molina, CA, Rovira, A, San Román, L, Serena, J, Abilleira, S, Ribó, M, et al; REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015;372:2296–2306. doi: 10.1056/NEJMoa1503780 DOI: https://doi.org/10.1056/NEJMoa1503780

Saver, JL, Goyal, M, Bonafe, A, Diener, HC, Levy, EI, Pereira, VM, Albers, GW, Cognard, C, Cohen, DJ, Hacke, W, et al; SWIFT PRIME Investigators. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372:2285–2295. doi: 10.1056/NEJMoa1415061 DOI: https://doi.org/10.1056/NEJMoa1415061

Campbell, BC, Mitchell, PJ, Kleinig, TJ, Dewey, HM, Churilov, L, Yassi, N, Yan, B, Dowling, RJ, Parsons, MW, Oxley, TJ, et al; EXTEND-IA Investigators. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009–1018. doi: 10.1056/NEJMoa1414792 DOI: https://doi.org/10.1056/NEJMoa1414792

Published

15-01-2022

How to Cite

Alsomali, O. H., Alsulami, E. H., Alshammari, M. A., Altayawi, F. M., Alonezi, A. D., Kabi, A. H., Almutairi, A. Z., Almutairi, F. G., Alhuwayrini, S. S., Alotaibi, ‏Hamad M., Baurasien, ‏Bander K., & Alareefi, ‏Hind S. (2022). Recent developments and innovations in emergency department for the management and treatment of acute ischemic stroke. International Journal of Health Sciences, 6(S10), 1797–1815. https://doi.org/10.53730/ijhs.v6nS10.15131

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Vol. 6 No. S10 (2022)

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Peer Review Articles
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