Reperfusion

Most strokes are due to blockage of an artery in the brain by a blood clot. Prompt treatment with reperfusion therapies can restore blood flow before major brain damage has occurred, and help people to make a good recovery from their stroke.

Thrombolysis dissolves blood clots using agents like recombinant tissue plasminogen activator (rt-PA). However, thrombolytic drugs can also cause serious bleeding in the brain, which can be fatal.

Thrombolytic therapy has been evaluated in many randomised trials, and in October 2003 the drug alteplase was licensed by the Australian Therapeutic Goods Administration for use in acute ischaemic stroke.

Numerous studies have demonstrated that treatment of up to 20% of all ischaemic stroke patients is achievable. Access remains lower in Australia, with an overall thrombolysis rate of 11% in the National Stroke Audit in 2021.

Although intravenous rt-PA improves survival and functional outcomes when administered as early as possible after onset of ischaemic stroke, its use is limited by the narrow therapeutic time window, important contraindications, and limited efficacy in patients with proximal large arterial occlusions. This has led to substantial interest in endovascular therapies for acute ischaemic stroke in recent years.

Endovascular thrombectomy (also called mechanical thrombectomy or endovascular clot retrieval) is a minimally invasive neurointervention procedure performed via angiogram. In most cases the femoral artery is accessed via the groin, and a small tube (catheter) passed up into the brain to the site of the blocked blood vessel. Various techniques are then available to the neurointerventionist to remove the clot. Stent retrievers (a metal net that can be deployed in the clot and then removed under suction) were the devices most commonly used in positive randomised trials.

When fully implemented, endovascular thrombectomy may be applicable for up to 10% of all ischaemic stroke patients, and these represent the group most likely to sustain death and disability if rapid restoration of blood flow is not achieved.

For current research and evidence-based recommendations see our Clinical Guidelines.