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Advances in stroke medicine

Bruce CV Campbell
Med J Aust 2019; 210 (8): . || doi: 10.5694/mja2.50137
Published online: 6 May 2019

Summary

  • In recent years, reperfusion therapies such as intravenous thrombolysis and endovascular thrombectomy for ischaemic stroke have dramatically reduced disability and revolutionised stroke management.
  • Thrombolysis with alteplase is effective when administered to patients with potentially disabling stroke, who are not at high risk of bleeding, within 4.5 hours of the time the patient was last known to be well. Emerging evidence suggests that other thrombolytics such as tenecteplase may be even more effective. Treatment may be possible beyond 4.5 hours in patients selected using brain imaging.
  • Endovascular thrombectomy (via angiography) effectively reduces risk of death or dependency in patients with large vessel occlusion (internal carotid, proximal middle cerebral and basilar arteries) if applied within 6 hours of the time they were last known to be well.
  • Endovascular thrombectomy is also beneficial 6–24 hours from the last known well time in selected patients with favourable brain imaging. Thus, some patients with wake‐up stroke are now treatable, and protocols for stroke need to include computed tomography (CT) perfusion scan and CT angiography as routine, in addition to the non‐contrast CT brain scan.
  • Optimised pre‐hospital and emergency department systems (eg, code stroke response teams, pre‐notification by ambulance, direct transport from triage to CT scanner) are essential to maximise the benefit of these strongly time‐dependent therapies. Telemedicine is increasingly providing specialist guidance for these more complex treatment decisions in rural areas.
  • Important developments in secondary stroke prevention include the use of direct oral anticoagulants or left atrial appendage occlusion for atrial fibrillation, and endovascular closure of patent foramen ovale.
  • Bruce CV Campbell

  • Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC

Correspondence: Bruce.Campbell@mh.org.au

Competing interests:

Bruce Campbell has received research support from the National Health and Medical Research Council (GNT1043242, GNT1035688), the Royal Australasian College of Physicians, the Royal Melbourne Hospital Foundation, the National Heart Foundation and the Stroke Foundation. He has received unrestricted grant funding for the EXTEND‐IA trial to the Florey Institute of Neuroscience and Mental Health from Medtronic. He co‐chaired the 2017 Australian Stroke Guidelines content working party.

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