title: Acute stroke intervention: a systematic review.
abstract: OBJECTIVE
  Acute ischemic stroke is a major cause of mortality and morbidity in the United States. We review the latest data and evidence supporting catheter-directed treatment for proximal artery occlusion as an adjunct to intravenous thrombolysis in patients with acute stroke.
  
  
  OBJECTIVE
  To review the pathophysiology of acute brain ischemia and infarction and the evidence supporting various stroke reperfusion treatments.
  
  
  METHODS
  Systematic literature search of MEDLINE databases published between January 1, 1990, and February 11, 2015, was performed to identify studies addressing the role of thrombolysis and mechanical thrombectomy in acute stroke management. Studies included randomized clinical trials, observational studies, guideline statements, and review articles. Sixty-eight articles (N = 108,082 patients) were selected for review.
  
  
  RESULTS
  Intravenous thrombolysis is the mainstay of acute ischemic stroke management for any patient with disabling deficits presenting within 4.5 hours from symptom onset. Randomized trials have demonstrated that more patients return to having good function (defined by being independent and having slight disability or less) when treated within 4.5 hours after symptom onset with intravenous recombinant tissue plasminogen activator (IV rtPA) therapy. Mechanical thrombectomy in select patients with acute ischemic stroke and proximal artery occlusions has demonstrated substantial rates of partial or complete arterial recanalization and improved outcomes compared with IV rtPA or best medical treatment alone in multiple randomized clinical trials. Regardless of mode of reperfusion, earlier reperfusion is associated with better clinical outcomes.
  
  
  CONCLUSIONS
  Intravenous rtPA remains the standard of care for patients with moderate to severe neurological deficits who present within 4.5 hours of symptom onset. Outcomes for some patients with acute ischemic stroke and moderate to severe neurological deficits due to proximal artery occlusion are improved with endovascular reperfusion therapy. Efforts to hasten reperfusion therapy, regardless of the mode, should be undertaken within organized stroke systems of care.
authors: Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors: Shyam
authors: S
authors: Prabhakaran
authors: Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors: Ilana
authors: I
authors: Ruff
authors: Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors: Richard A
authors: RA
authors: Bernstein
mesh_terms: D001921:Brain / Q000378:metabolism / Q000473:pathology; D020520:Brain Infarction; D002545:Brain Ischemia; D057510:Endovascular Procedures; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D007262:Infusions, Intravenous; D015424:Reperfusion / Q000379:methods; D020521:Stroke / Q000175:diagnosis / Q000628:therapy*; D017131:Thrombectomy; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator