Reperfusion therapy for acute ischemic stroke: where are we in 2023?

Over the last three decades, stroke care has undergone significant transformations mainly driven by the introduction of reperfusion therapy and the organization of systems of care. Patients receiving treatment through a well-structured stroke service have a much higher chance of favorable outcomes, thereby decreasing both disability and mortality. In this article, we reviewed the scientific evidence for stroke reperfusion therapy, including thrombolysis and thrombectomy, and its implementation in the public health system in Brazil.

Keywords
Stroke; Ischemic Stroke; Reperfusion; Thrombolytic Therapy; Thrombectomy

Authorship

Sheila Cristina Ouriques Martins Address for correspondence Sheila Cristina Ouriques Martins (email: sheila@redebrasilavc.org.br)

conceptualization

data curation

methodology

project administration

writing – original draft

writing – review & editing

Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Porto Alegre RS, Brazil.Universidade Federal do Rio Grande do SulBrazilPorto Alegre, RS, BrazilUniversidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Porto Alegre RS, Brazil.

Hospital Moinhos de Vento, Porto Alegre RS, Brazil.Hospital Moinhos de VentoBrazilPorto Alegre, RS, BrazilHospital Moinhos de Vento, Porto Alegre RS, Brazil.

https://orcid.org/0000-0002-8452-712X

Octávio Marques Pontes- Neto

data curation

validation

writing – review & editing

Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto SP, Brazil.Universidade de São PauloBrazilRibeirão Preto, SP, BrazilUniversidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto SP, Brazil.

https://orcid.org/0000-0003-0317-843X

Arthur Pille

investigation

writing – review & editing

Hospital Moinhos de Vento, Porto Alegre RS, Brazil.Hospital Moinhos de VentoBrazilPorto Alegre, RS, BrazilHospital Moinhos de Vento, Porto Alegre RS, Brazil.

https://orcid.org/0009-0007-6274-2420

Thaís Leite Secchi

writing – review & editing

Hospital Moinhos de Vento, Porto Alegre RS, Brazil.Hospital Moinhos de VentoBrazilPorto Alegre, RS, BrazilHospital Moinhos de Vento, Porto Alegre RS, Brazil.

https://orcid.org/0000-0001-5214-7037

Maramélia Araújo de Miranda Alves

data curation

validation

writing – review & editing

Universidade Federal de São Paulo, Hospital São Paulo, São Paulo SP, Brazil.Universidade Federal de São PauloBrazilSão Paulo, SP, BrazilUniversidade Federal de São Paulo, Hospital São Paulo, São Paulo SP, Brazil.

https://orcid.org/0000-0002-8284-1991

Letícia Costa Rebello

validation

Hospital de Base de Brasília, Brasília DF, Brazil.Hospital de Base de BrasíliaBrazilBrasília, DF, BrazilHospital de Base de Brasília, Brasília DF, Brazil.

https://orcid.org/0000-0002-7254-6710

Jamary Oliveira- Filho

validation

Universidade Federal da Bahia, Salvador BA, Brazil.Universidade Federal da BahiaBrazilSalvador, BrazilUniversidade Federal da Bahia, Salvador BA, Brazil.

https://orcid.org/0000-0003-1915-0423

Marcos Christiano Lange

validation

Universidade Federal do Paraná, Hospital de Clínicas, Curitiba PR, Brazil.Universidade Federal do ParanáBrazilCuritiba, PR, BrazilUniversidade Federal do Paraná, Hospital de Clínicas, Curitiba PR, Brazil.

https://orcid.org/0000-0002-0405-7157

Gabriel R. de Freitas

validation

Hospital Quinta D'Or, Rio de Janeiro RJ, Brazil.Hospital Quinta D'OrBrazilRio de Janeiro, RJ, BrazilHospital Quinta D'Or, Rio de Janeiro RJ, Brazil.

https://orcid.org/0000-0003-3178-0460

João Brainer Clares de Andrade

validation

https://orcid.org/0000-0001-8768-7164

Letícia Januzi de Almeida Rocha

validation

Hospital Universitário Professor Alberto Antunes, Maceió AL, Brazil.Hospital Universitário Professor Alberto AntunesBrazilMaceió, AL, BrazilHospital Universitário Professor Alberto Antunes, Maceió AL, Brazil.

https://orcid.org/0000-0003-2738-9346

Daniel da Cruz Bezerra

validation

Hospital Pró-Cardíaco, Rio de Janeiro RJ, Brazil.Hospital Pró-CardíacoBrazilRio de Janeiro, RJ, BrazilHospital Pró-Cardíaco, Rio de Janeiro RJ, Brazil.

https://orcid.org/0000-0002-2530-4970

Ana Claudia de Souza

validation

Hospital Moinhos de Vento, Porto Alegre RS, Brazil.Hospital Moinhos de VentoBrazilPorto Alegre, RS, BrazilHospital Moinhos de Vento, Porto Alegre RS, Brazil.

https://orcid.org/0000-0002-8722-9988

Leonardo Augusto Carbonera

validation

Hospital Moinhos de Vento, Porto Alegre RS, Brazil.Hospital Moinhos de VentoBrazilPorto Alegre, RS, BrazilHospital Moinhos de Vento, Porto Alegre RS, Brazil.

https://orcid.org/0000-0002-9313-7967

Raul Gomes Nogueira

validation

University of Pittsburgh, Pittsburgh PA, United States.University of PittsburghUnited StatesPittsburgh, PA, United StatesUniversity of Pittsburgh, Pittsburgh PA, United States.

https://orcid.org/0000-0003-4532-153X

Gisele Sampaio Silva

data curation

validation

writing – review & editing

https://orcid.org/0000-0002-3247-3123

Address for correspondence Sheila Cristina Ouriques Martins (email: sheila@redebrasilavc.org.br)

Conflict of Interest

SCOM reports receiving research grant from the Ministry of Health for Resilient Trial and Resilient-Extend, Research grant from Hospital Moinhos de Vento/PROADI SUS for Resilient-Direct TNK, Resilient Extend-IV, TRIDENT and PROMOTE Study. Speaker fees from Boehringer Ingelheim, Bayer, Pfizer, Daiichi Sanchio, Novo Nordisk, Servier, Novartis, Medtronic, Penumbra, Astra Zeneca and RAPID IA. OMPN reports speaker fees from Boehringer Ingelheim, Astra Zeneca, RAPIDIA, Pfizer; Advisory board of Astra Zeneca, Boehringer Ingelheim RAPIDIA, ALLM. AP reports speaker fees from Boehringer Ingelheim. LCR reports speaker fees from Astra Zeneca and Boehringer Ingelheim. GRF reports speaker fees from Bayer and Pfizer. JBCA reports speaker fees from Astra Zeneca. ACS received a restricted grant from Boehringer Ingelheim. LAC reports receiving a restricted grant from the World Stroke Organization outside of this work and consulting and speaker fees from Allm, Astra Zeneca, Boehringer Ingelheim, and ISchemaView. RGN reports consulting fees for advisory roles with Anaconda, Biogen, Cerenovus, Genentech, Philips, Hybernia, Imperative Care, Medtronic, Phenox, Philips, Prolong Pharmaceuticals, Stryker Neurovascular, Shanghai Wallaby, Synchron, and stock options for advisory roles with Astrocyte, Brainomix, Cerebrotech, Ceretrieve, Corindus Vascular Robotics, Vesalio, Viz-AI, RapidPulse and Perfuze. RGN is one of the Principal Investigators of the “Endovascular Therapy for Low NIHSS Ischemic Strokes (ENDOLOW)” trial. RGN is the Principal Investigator of the “Combined Thrombectomy for Distal MediUm Vessel Occlusion StroKe (DUSK)” trial. RGN is an investor in Viz-AI, Perfuze, Cerebrotech, Reist/Q'Apel Medical, Truvic, Vastrax, and Viseon. TLS, MMR, JOF, MCL, LJAR, DCB have no disclosures to declare.

SCIMAGO INSTITUTIONS RANKINGS

Hospital Moinhos de Vento, Porto Alegre RS, Brazil.Hospital Moinhos de VentoBrazilPorto Alegre, RS, BrazilHospital Moinhos de Vento, Porto Alegre RS, Brazil.

Hospital de Base de Brasília, Brasília DF, Brazil.Hospital de Base de BrasíliaBrazilBrasília, DF, BrazilHospital de Base de Brasília, Brasília DF, Brazil.

Universidade Federal da Bahia, Salvador BA, Brazil.Universidade Federal da BahiaBrazilSalvador, BrazilUniversidade Federal da Bahia, Salvador BA, Brazil.

Hospital Quinta D'Or, Rio de Janeiro RJ, Brazil.Hospital Quinta D'OrBrazilRio de Janeiro, RJ, BrazilHospital Quinta D'Or, Rio de Janeiro RJ, Brazil.

Hospital Pró-Cardíaco, Rio de Janeiro RJ, Brazil.Hospital Pró-CardíacoBrazilRio de Janeiro, RJ, BrazilHospital Pró-Cardíaco, Rio de Janeiro RJ, Brazil.

University of Pittsburgh, Pittsburgh PA, United States.University of PittsburghUnited StatesPittsburgh, PA, United StatesUniversity of Pittsburgh, Pittsburgh PA, United States.

Figures

Figures (5)

Thumbnail

Figure 1
Odds ratio for favorable prognosis at three months in patients treated with tPA compared with controls by the time of initiation of treatment. (Adapted from Lancet 2004¹³13 The ATLANTIS, ECASS, and NINDS rt-PA study group investigators. Association of outcome with early stroke treatment: Pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004;363:768–774 PubMed).

Thumbnail

Figure 2
Recanalization rates with tPA by affected segment.

Thumbnail

Figure 3
Relationship between time from onset of symptoms in treatment and functional outcome (adapted from Saver, JAMA 2016³⁵35 Kidwell CS, Jahan R, Gornbein J, et al; MR RESCUE Investigators. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 2013;368(10):914–923).

Thumbnail

Figure 4
Relationship between door-reperfusion time and functional outcome (adapted from Saver, JAMA 2016³⁵35 Kidwell CS, Jahan R, Gornbein J, et al; MR RESCUE Investigators. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 2013;368(10):914–923).

Thumbnail

Figure 5
Main milestones in the implementation of reperfusion therapy in Brazil.

Thumbnail

Figure 5
Main milestones in the implementation of reperfusion therapy in Brazil.

Figure 1 Odds ratio for favorable prognosis at three months in patients treated with tPA compared with controls by the time of initiation of treatment. (Adapted from Lancet 2004¹³13 The ATLANTIS, ECASS, and NINDS rt-PA study group investigators. Association of outcome with early stroke treatment: Pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004;363:768–774 PubMed).

Figure 2 Recanalization rates with tPA by affected segment.

Figure 3 Relationship between time from onset of symptoms in treatment and functional outcome (adapted from Saver, JAMA 2016³⁵35 Kidwell CS, Jahan R, Gornbein J, et al; MR RESCUE Investigators. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 2013;368(10):914–923).

Figure 4 Relationship between door-reperfusion time and functional outcome (adapted from Saver, JAMA 2016³⁵35 Kidwell CS, Jahan R, Gornbein J, et al; MR RESCUE Investigators. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 2013;368(10):914–923).

Figure 5 Main milestones in the implementation of reperfusion therapy in Brazil.

Figure 3 Relationship between time from onset of symptoms in treatment and functional outcome (adapted from Saver, JAMA 2016³⁵35 Kidwell CS, Jahan R, Gornbein J, et al; MR RESCUE Investigators. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 2013;368(10):914–923).

Figure 4 Relationship between door-reperfusion time and functional outcome (adapted from Saver, JAMA 2016³⁵35 Kidwell CS, Jahan R, Gornbein J, et al; MR RESCUE Investigators. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 2013;368(10):914–923).

Figure 5 Main milestones in the implementation of reperfusion therapy in Brazil.

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