Interventional Treatment and Management of Ischemic Stroke J Vasc Interv Radiol 2004; 15:S1
CURRENTLY in North America, stroke and cerebrovascular diseases are the third leading cause of death and a leading cause of adult disability. There are more than 750,000 new cases annually, resulting in more than 250,000 new disability cases and more than 200,000 deaths per year. The National Institutes of Health (NIH) and the American Stroke Association currently estimate that the annual cost of stroke care in the United States now exceeds $50 billion, of which $30 billion is due to direct health care costs resulting from hospitalization, physician fees, procedure costs, and rehabilitation. In excess of $20 billion is due to lost productivity, since the majority of patients are disabled and cannot return to their normal lifestyle or to work, and may require extended care. The majority of stroke cases are due to ischemic causes including thrombo-emboli from carotid and intracranial atherosclerosis, or from the heart and great vessels. Less than 20% of stroke cases are due to hemorrhagic causes, such as a ruptured cerebral aneurysm or brain vascular malformation. Rapid advances in the diagnosis, medical therapy, and endovascular and interventional treatments have significantly impacted this disease process over the past decade. Technologic imaging advancements in computed tomography (CT), magnetic resonance (MR) imaging, CT angiography and MR angiography, and perfusion/diffusion imaging, have significantly improved our diagnostic armamentarium. More accurate diagnosis, combined with functional imaging, has increased our awareness of the etiology and provided valuable therapeutic alternatives for treatment. In this special supplementary issue of JVIR, we have focused on the interventional treatment and management of ischemic stroke. We have asked nationally recognized experts in their field to discuss “state of the art” approaches to the pathophysiology of acute ischemic stroke, the hemodynamic and molecular basis of carotid and cerebral atherosclerosis, and physiologic monitoring and anesthetic considerations of the acute stroke patient. We review critical care assessment, followed by imaging of cerebral blood flow, CT, MR imaging, and cerebral angiography assessment of the stroke patient. We then provide an overview of all of the past and current thrombolytic trials in acute ischemic stroke, including the NIH National Institute of Neurological Disorders and Stroke (NINDS) tissue plasminogen activator trial, which was the basis for approval of intravenous tPA in acute ischemic stroke, within 3 hours from symptom onset in 1996. This is followed by a review of the current
intra-arterial stroke trials, and combination drug therapies, now under investigation. In the final section, we discuss current and future directions of acute ischemic stroke treatments, including novel pharmacological therapies with other thrombolytics, glycoprotein IIB/IIIa inhibitors, mechanical devices for cerebral clot removal including snares, laser devices, and suction-thrombectomy microcatheters, now in Phase I/II trials in North America, or planned in the near future. We conclude with a critical evaluation of intracranial atherosclerosis and current treatment with balloon angioplasty and stent placement, and finally discuss the practical implications for developing a “stroke center of excellence” at the local level within your own hospital. This special supplementary issue of the Journal of Vascular and Interventional Radiology was written as a joint effort of the Society of Interventional Radiology (SIR) and the American Society of Interventional and Therapeutic Neuroradiology (ASITN). We hope that this JVIR supplement will provide the necessary scientific, clinical, and practical approaches for developing a rational stroke treatment approach within your current practice. This is a very exciting time for the interventional radiology, neurology, and stroke community, and we believe that stroke treatment will continue to evolve into a dynamic, important, and vital part of both the academic and community hospital, and the interventional and diagnostic radiology practice.
Randall T. Higashida, MD Division of Interventional Neurovascular Radiology University of California San Francisco Medical Center San Francisco, California
Jacques Dion, MD Interventional Neuroradiology Division Department of Radiology Emory University Hospital Atlanta, Georgia