Intervention in acute cerebral ischaemic stroke: a review of the role of pharmacological therapies and intra-arterial mechanical thrombectomy devices

Acute ischaemic stroke (AIS) is the leading cause of death and disability in developed nations. In the past decade pharmacologic and endovascular therapy has been approved for use in treatment of patients presenting with AIS. The time window from symptom onset to be eligible for treatment is narrow, allowing for only a small proportion of these patients to be treated. Currently the established method of treatment is intravenous thrombolytic therapy for patients without contraindication, presenting within the time window of 4.5 h from the onset of symptoms. The improvement in patient outcome with this therapy is poor. This has led to exploration of intra-arterial mechanical thrombectomy devices to both increase the time window and also attempt to improve patient outcome with and without intravenous thrombolytic therapy. Several studies have shown a high rate of vessel recanalisation with endovascular techniques; however, their efficacy and translation to improved patient outcome is not yet established. Advanced imaging techniques may help select patients who would predictably benefit from endovascular intervention. In the light of existing controversies, this review discusses the current evidence for intravenous and intra-arterial thrombolytics, intra-arterial mechanical thrombectomy devices, and intracranial stent placement for treatment of AIS.