Intra-arterial Thrombolysis for the Treatment of Patients with Acute Ischemic Stroke

In this issue of the AJNR, Edwards and colleagues (page 1682) describe their experiences with the use of intra-arterial thrombolytic therapy for the treatment of patients with acute ischemic stroke. The report is noteworthy on at least two counts. First, it demonstrates unequivocally both the feasibility and practicality of implementing an aggressive and effective protocol for the treatment of acute ischemic stroke in a community hospital outside of a major urban area. It also serves as an excellent example of the type of important and innovative clinical research that can be conducted in medical facilities located outside of the walls of a university setting. In spite of increasingly convincing evidence that there is considerable benefit to be derived from the use of aggressive endovascular techniques in the management of properly selected patients with acute ischemic stroke, many institutions still either do not provide these treatment options or only offer them on what might be termed an ad hoc basis. Several explanations are commonly offered in defense of the inability to offer these services. Two of the most common are: 1) there are not enough interventional neuroradiologists to provide round-the-clock, 7-day-per-week coverage; and 2) the institution does not have adequate resources to make available either the necessary technology or the in-house staff (technician and physician) coverage required for such a service.

Although physicians with specialized training in interventional neuroradiology should, because of their special skills (technical and cognitive), enhance the function of a “stroke team,” it does not follow that “teams” without such members cannot also be effective. Using currently available microcatheters and guidewires, most physicians having significant experience performing diagnostic angiograms can be taught to perform catheterization on those intracranial arteries that are most commonly implicated in the etiology of ischemic stroke safely. It is much more difficult to provide training so that one understands issues such as when and when not to perform a particular intervention and what to do when things go wrong than it is to teach the technical skills required for the intervention itself. In my opinion, this hurdle may be quickly lowered and ultimately removed by establishment of “teams” such as the one described in the report by Edwards and colleagues. Unlike large academic centers where the personnel of stroke teams (technicians, residents, fellows, and staff) may be under considerable flux, the team described by Edwards was small, stable, and focused. Such an environment provides an ideal venue for each patient encounter to result in all members of the team expanding their understanding of “what went right and what went wrong” thereby “training” not only themselves but also the team for improved performance with each new experience. The reality is that if the vast numbers of patients who suffer an ischemic stroke each year in North America are to benefit from current and evolving therapeutic options, physicians other than formally trained interventional neuroradiologists and neurologists must be recruited to be members of stroke teams.

Recent studies provide some indication that the major reason for patients with ischemic stroke being ineligible for thrombolytic therapy is delay in obtaining treatment. While both access to rapid CT imaging and accurate interpretation of scan findings are critical if acute ischemic stroke intervention is to be safe and successful, neither issue need preclude offering such treatment in hospitals such as the one described by Edwards and colleagues. It seems certain that rapidly evolving MR techniques (diffusion and perfusion imaging) will greatly enhance the ability to distinguish between those patients having an “open therapeutic window” and those in whom the “window is closed.” The resulting improvement in stratifying individuals into appropriate treatment protocols ought to increase the number of patients who are potential candidates for thrombolytic therapy. A further increase in the patient population suitable for aggressive endovascular treatment likely will occur as a number of promising techniques for mechanical thrombolysis and nonpharmacologic methods of providing “brain protection,” ie, regional hypothermia, become available. As these techniques are commercialized, not only tertiary-care medical centers but also many community hospitals have adequate technology and personnel in place to implement them into their practice. As noted by Hill and Hachinski: “Nihilistic attitudes about stroke treatment are now archaic because the future holds much promise for stroke patients (1).” Edwards and colleagues have shown enthusiasm, dedication, and skill in carrying out the study reported in this issue of the Journal. This could serve as a model for implementing an interventional stroke service in other community hospital settings.