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.
SUMMARY: 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.
KEY MESSAGE: 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.