Now that the door is open: an update on ischemic stroke pharmacotherapeutics for the neurointerventionalist

No Harmful Effect of Endovascular Treatment before Decompressive Surgery-Implications for Handling Patients with Space-Occupying Brain Infarction

This study explored short- and mid-term functional outcomes in patients undergoing decompressive hemicraniectomy (DHC) due to space-occupying cerebral infarction and asked whether there is a potentially harmful effect of a priorly performed endovascular treatment (EVT). Medical records were screened for patients requiring DHC due to space-occupying cerebral infarction between January 2016 and July 2021. Functional outcomes at hospital discharge and at 3 months were assessed by the modified Rankin Scale (mRS). Out of 65 patients with DHC, 39 underwent EVT before DHC. Both groups, i.e., EVT + DHC and DHC alone, had similar volumes (280 ± 90 mL vs. 269 ± 73 mL, t-test, p = 0.633) and proportions of edema and infarction (22.1 ± 6.5% vs. 22.1 ± 6.1%, t-test, p = 0.989) before the surgical intervention. Patients undergoing EVT + DHC tended to have a better functional outcome at hospital discharge compared to DHC alone (mRS 4.8 ± 0.8 vs. 5.2 ± 0.7, Mann-Whitney-U, p = 0.061), while the functional outcome after 3 months was similar (mRS 4.6 ± 1.1 vs. 4.8 ± 0.9, Mann-Whitney-U, p = 0.352). In patients initially presenting with a relevant infarct demarcation (Alberta Stroke Program Early CT Score ≤ 5), the outcome was similar at hospital discharge and after 3 months between patients with EVT + DHC and DHC alone. This study provided no evidence for a harmful effect of EVT before DHC in patients with space-occupying brain infarction.

Neuroprotection during Thrombectomy for Acute Ischemic Stroke: A Review of Future Therapies

Stroke is a major cause of death and disability worldwide. Endovascular thrombectomy has been impactful in decreasing mortality. However, many clinical results continue to show suboptimal functional outcomes despite high recanalization rates. This gap in recanalization and symptomatic improvement suggests a need for adjunctive therapies in post-thrombectomy care. With greater insight into ischemia-reperfusion injury, recent preclinical testing of neuroprotective agents has shifted towards preventing oxidative stress through upregulation of antioxidants and downstream effectors, with positive results. Advances in multiple neuroprotective therapies, including uric acid, activated protein C, nerinetide, otaplimastat, imatinib, verapamil, butylphthalide, edaravone, nelonemdaz, ApTOLL, regional hypothermia, remote ischemic conditioning, normobaric oxygen, and especially nuclear factor erythroid 2-related factor 2, have promising evidence for improving stroke care. Sedation and blood pressure management in endovascular thrombectomy also play crucial roles in improved stroke outcomes. A hand-in-hand approach with both endovascular therapy and neuroprotection may be the key to targeting disability due to stroke.

A Stroke of Bad Luck: An Autobiographical Case Report

Strokes are a common cause of death. Cardiovascular disease, including atrial fibrillation and atrial flutter, is a frequent cause of ischemic strokes. A 64-year-old man developed isolated dysarthria without any other neurologic manifestations as the presentation of an ischemic stroke resulting from occlusion to the middle cerebral artery and affecting the cortex supplied by the artery. He was discovered to be in atrial flutter which was determined to be the likely etiology of his stroke. He was hospitalized and anticoagulated with heparin; as an outpatient, his anticoagulation was maintained with the direct oral anticoagulant apixaban. Amiodarone was required to medically convert him to normal sinus rhythm; he has typical atrial flutter and is going to be evaluated for atrial flutter ablation. His dysarthria began to improve within 24 hours after he experienced the stroke; after five weeks of speech therapy his ability to talk continues to progressively improve and the residual deficits in his speech continue to resolve. Anticoagulation is required for stroke prevention in individuals with atrial fibrillation and atrial flutter. Warfarin, a vitamin K antagonist, is usually used for individuals with valvular atrial fibrillation. Direct oral anticoagulants have fewer bleeding complications and are usually recommended for nonvalvular atrial fibrillation; they include the direct thrombin inhibitor dabigatran or a factor ten a (Xa) inhibitor such as either apixaban, edoxaban, or rivaroxaban. Dysarthria is a common manifestation in stroke patients. Albeit, it is less common, isolated dysarthria without any other neurologic sequellae may be associated with stroke. Interventions encouraged by speech pathologists to enhance the resolution of post-stroke dysarthria include speaking louder to amplify the voice and exaggerating the movements of the mouth when speaking.