Endovascular
therapy with mechanical
thrombectomy is a formidable treatment for severe
acute ischemic stroke caused by occlusion of a proximal intracranial artery. Its strong beneficial effect is explained by the high rates of very good and excellent reperfusion achieved with current
endovascular techniques. However, there is a sizable proportion of patients who do not experience clinical improvement despite successful recanalization of the occluded artery and reperfusion of the ischemic territory. Factors such as baseline reserve, collateral flow,
anesthesia and systemic factors have been identified as potential culprits for lack of improvement in the setting of timely and successful revascularization. Older age, baseline disability and perhaps radiological markers of
chronic brain injury can affect the prognosis of patients treated with endovascular
therapy. Collateral flow is a major determinant of outcome after endovascular
therapy and it is manifested by the size of the core in relation to the volume of the salvageable tissue. Parenchymal and vascular imaging can help assess the quality of collateral flow, but the optimal radiological strategy for daily practice (i.e. the optimal combination of rapid availability and diagnostic precision) has not been established. A sizable body of observational evidence indicates that acute
hypertension,
hyperglycemia and
fever are associated with worse outcomes after a
stroke even after optimal reperfusion with endovascular
therapy. Lastly, current randomized controlled trials in
anesthesia for
stroke demonstrate similar rates of good functional outcome between
general anesthesia and
conscious sedation suggesting
equipoise exists.