Endovascular recanalization in acute ischemic stroke

It is time to systematically plan for the next era in reperfusion therapy for acute ischemic stroke—the epoch of endovascular treatment.

Reperfusion therapies for acute arterial occlusions in different organ beds naturally evolve in 2 successive eras. In the first, IV thrombolysis (IVT) launches the reperfusion age, as the first useful, widely disseminated therapy, but its success is constrained by only modest recanalization rates. Then, in the second, endovascular recanalization techniques (ERTs) are developed that are far more effective at achieving reperfusion and supersede IVT alone to become the definitive, ongoing standard of care. This 2-stage pattern characterized the evolution of reperfusion therapy for both acute myocardial ischemia and acute limb ischemia. Reflecting the greater complexity and fragility of the brain and its vasculature, the evolution of acute ischemic stroke care has been slower but now can be seen to be also traversing this same historical path.

The decades from 1990 to 2010 were the era of IVT for acute ischemic stroke, as IVT evolved from untested therapy through clinical trial–validated intervention to standard therapy embedded in nationwide hospital systems of care.

We are now living and working in the early phase of the era of ERTs. The initial period of rapid, iterative technologic advance has been proceeding apace, as the endovascular armamentarium has expanded from intra-arterial …