2024 Volume 41 Issue 5 Pages 717-721
Advance in acute reperfusion therapy: Indications of mechanical thrombectomy (MT) for acute stroke due to large vessel occlusion (LVO) is expanding, especially in patients with large ischemic regions. Six randomized trials (RESCUE–Japan LIMIT, SELECT–2, ANGEL–ASPECTS, TENSION, LASTE, TESLA) has been reported, and five of them revealed the efficacy and safety of MT compared to medical management. However, it should be noted that many patients will be disable even if successful reperfusion was achieved. MR–CLEAN LATE verified efficacy of MT in patients with late presenting stroke due to LVO, without using perfusion images or infarct volume measurements. Regarding the direct MT versus bridging with intravenous thrombolysis, a meta–analysis of six randomized trials (IRIS study) showed non–inferiority of MT, whereas bridging therapy seemed to be more effective within 140 minutes of onset. TRACE–2 clarified non–inferiority of thrombolysis using tenecteplase compared to alteplase in acute stroke patients within 4.5 hours of onset. The ARAMIS trial showed non–inferiority of dual antiplatelet therapy compared to thrombolysis using alteplase in patients with mild neurological symptoms.
Advance in antithrombotic therapy: In the RESCUE BT2 trial, tirofiban (glycoprotein IIb/IIIa inhibitor) is more effective in acute ischemic stroke patients without LVO or medium vessel occlusions compared to aspirin. ELAN is a randomized trial of direct oral anticoagulant (DOAC) initiation for the composite endpoint of recurrent ischemic stroke, systemic embolism, major extracranial bleeding, symptomatic intracranial hemorrhage, or vascular death within 30 days after randomization. Participants were randomly assigned early or later anticoagulation based on stroke severity, and the incidence of composite endpoint was similar between two groups.
