Optimizing reperfusion strategies for acute ischemic stroke: Towards imaging-based, individualized intravenous and endovascular treatment

Outcomes after acute ischemic stroke have greatly improved due to new treatment options that can achieve fast reperfusion. Intravenous alteplase was proven effective as a thrombolytic, and endovascular treatment (EVT) greatly improved outcomes for patients with large, proximal occlusions. Despite this progress however, today, still nearly 30% of large occlusion patients die or remain dependent on daily nursing care after stroke. The goal of this thesis was to investigate three ways to further improve patient outcomes after stroke by optimizing reperfusion strategies.
Part I describes the progress of EVT. In a literature review, we summarize results of EVT approaches in the most proximal large vessel occlusions. Subsequently, we describe results of EVT in daily practice from 2014-2017. Outcomes continue to improve, most likely due to faster workflow and improved reperfusion rates.
In Part II, we studied imaging factors that could (or should not) guide imaging-based stroke treatment selection for each patient. We found that patients with early ischemic changes on CT could still benefit from reperfusion by EVT. Furthermore, we found that patients with pervious thrombi, thrombi that are permeable to contrast, showed a better response to intravenous alteplase.
Part III of this thesis focuses on intravenous alteplase administration before EVT. In the final two chapters, the design and results of an international, multicenter randomized controlled trial on intravenous alteplase administration prior to EVT are described: MR CLEAN-NO IV.
Acute ischemic stroke care is complex, evolving, and improving. Individualized treatment selection based on patient-specific, clinical, and imaging-based factors may allow us to further improve reperfusion rates and thereby clinical outcomes.