Acute ischemic stroke management: concepts and controversies.A narrative review

ABSTRACT

Introduction

Amongst the 25.7 million survivors and 6.5 million deaths from stroke between 1990 and 2013, ischemic strokes accounted for approximately 70% and 50% of the cases, respectively. With patients still suffering from complications and stroke recurrence, more questions have been raised as to how we can better improve patient management.

Areas covered

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Newcastle-Ottawa Scale (NOS) were adopted to ensure a comprehensive inclusion of quality literature from various sources. PubMed and Embase were searched for evidence on thrombolysis, mechanical thrombectomy, artificial intelligence (AI), antiplatelet therapy, anticoagulation and hypertension management.

Expert opinion

The directions of future research in these areas are dependent on the current level of validation. Endovascular therapy and applications of AI are relatively new compared to the other areas discussed in this review. As such, future studies need to focus on validating their efficacy. As for thrombolysis, antiplatelet and anticoagulation therapy, their efficacy has been well-established and future research efforts should be directed toward adjusting its use according to patient-specific factors, starting with factors with the most clinical relevance and prevalence.

KEYWORDS:

• Stroke
• thrombolysis
• thrombectomy
• anticoagulation
• antiplatelet
• artificial intelligence

Article highlights

• Patient with confirmed small ischemic penumbra secondary to proximal occlusion are likely to benefit from mechanical thrombectomy (MT) and intravenous thrombolysis. Further validation studies into (1) the applications of MT in treating basilar occlusions, (2) the benefits of concurrent internal carotid artery stenting or dilation and (3) artificial intelligence software are required.

• Dual antiplatelet therapy post-ischemic stroke is superior to mono- and triple-therapy. There are currently ongoing trials looking into dual antiplatelet therapies involving ticagrelor and its optimal treatment duration.

• Direct oral anticoagulants (DOACs) are superior to warfarin for secondary prevention of stroke with lower bleeding risks. Research into DOAC dose adjustment in advanced chronic kidney disease and the optimum time to initiate DOAC post-stroke is currently underway.

• Maintaining tight blood pressure control is recommended throughout the different phases of stroke management. Further randomized trials are required to determine the ideal blood pressure range at each phase.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

A reviewer on this manuscript has previously received honoraria for lectures relevant to this review. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Supplementary material

Supplemental data for this article can be accessed here