title: Impact of Mechanical Thrombectomy on the Organization of the Management of Acute Ischemic Stroke.
abstract: BACKGROUND
  Several trials and meta-analyses have recently demonstrated the superiority of endovascular therapy over standard medical treatment in patients presenting with acute ischemic stroke. In order to offer the best possible treatment to a maximum number of patients, many stroke care networks probably have to be reorganized. After analyzing the reliability of data in the literature, an algorithm is suggested for a pre-hospital and in-hospital alert system to improve the timeliness of subsequent treatment: a drip-and-ship approach.
  
  
  CONCLUSIONS
  Five recent well-designed randomized studies have demonstrated the benefit of endovascular therapy associated with intravenous fibrinolysis by recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke with confirmation by recent meta-analyses. The keys for success are a very short time to reperfusion, within 6 h, a moderate to severe pre-treatment deficit (National Institute of Health around 17), cerebral imaging able to identify proximal large vessel occlusion in the anterior circulation, a limited infarct core and a reversible penumbra, the use of the most recent devices (stent retriever) and a procedure that avoids general anesthesia, which reduces blood pressure. To meet these goals, every country must build a national stroke infrastructure plan to offer the best possible treatment to all patients eligible for intravenous fibrinolysis and endovascular therapy. The plan may include the following actions: inform the population about the first symptoms of stroke, provide the call number to improve the timeliness of treatment, increase the number of comprehensive stroke centers, link these to secondary and primary stroke centers by telemedicine, teach and train paramedics, emergency doctors and radiologists to identify the stroke infarct, proximal large vessel occlusion and the infarct core quickly, train a new generation of endovascular radiologists to improve access to this therapy.
  
  
  CONCLUSIONS
  After 20 years of rt-PA, this new evidence-based therapy is a revolution in stroke medicine that will benefit patients. However, a new robust and multi-disciplinary care strategy is necessary to transfer the scientific data into clinical practice. It will require reorganization of the stroke infrastructure, which will include comprehensive stroke centers and secondary and primary stroke centers. The winners will be patients with severe stroke.
authors.affiliation: Stroke Registry of Dijon (Inserm, InVS, EA4184), University of Burgundy, Dijon, France.
authors.forename: Benoît
authors.initials: B
authors.lastname: Daubail
authors.forename: Frédéric
authors.initials: F
authors.lastname: Ricolfi
authors.forename: Pierre
authors.initials: P
authors.lastname: Thouant
authors.forename: Charlotte
authors.initials: C
authors.lastname: Vogue
authors.forename: Adrien
authors.initials: A
authors.lastname: Chavent
authors.forename: Guy-Victor
authors.initials: GV
authors.lastname: Osseby
authors.forename: Marie
authors.initials: M
authors.lastname: Hervieu-Begue
authors.forename: Benoit
authors.initials: B
authors.lastname: Delpont
authors.forename: Bruno
authors.initials: B
authors.lastname: Mangola
authors.forename: Yannick
authors.initials: Y
authors.lastname: Bejot
authors.forename: Maurice
authors.initials: M
authors.lastname: Giroud
mesh_terms: D057510:Endovascular Procedures / Q000379:methods*; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006739:Hospital Administration / Q000379:methods*; D006801:Humans; D015203:Reproducibility of Results; D015607:Stents; D020521:Stroke / Q000175:diagnosis / Q000628:therapy*; D017131:Thrombectomy / Q000295:instrumentation / Q000379:methods*; D015912:Thrombolytic Therapy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator