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Abstract
Purpose of the Review Mechanical thrombectomy (MT)–mediated endovascular recanalization has dramatically transformed treatment and outcomes after acute ischemic stroke caused by a large vessel occlusion (LVO). Current guidelines recommend MT up to 24 hours from stroke onset in carefully selected patients based on favorable clinical and imaging parameters. Despite optimal patient selection and low complication rates with current recanalization technology, approximately 1 in 2 patients with LVO stroke do not achieve functional independence at 3 months. This ceiling effect of MT efficacy may be explained by ischemic core expansion into the ischemic penumbra before recanalization and neuronal loss occurring after recanalization. Factors affecting the efficacy of MT, or the degree of irreversible injury, include time from symptom onset to recanalization, collateral circulation status, and differences in neuronal vulnerability. The purpose of this brief review is to discuss potential targets for neuroprotection, present and future potential pharmacologic and nonpharmacologic agents, and the data available in the literature.
Recent Findings In experimental ischemia models, several authors reported that pharmacologic and nonpharmacologic agents are able to slow the progression of ischemic core expansion. However, in the era of unsuccessful recanalization of the occluded artery, several neuroprotective agents that were promising in the preclinical stage failed phase II/III clinical trials.
Summary Providing neuroprotection before and after recanalization of an LVO may play an important role in improving outcomes in the era of MT. Neuroprotection is classically defined as a process that results in the salvage, recovery, or regeneration of neuronal (and other supporting CNS cell) structure or function. The advent of successful recanalization of acute LVO by MT in the majority of patients may spur the growth of effective neuroprotection.
Glossary
- AIS=
- acute ischemic stroke;
- APC=
- activated protein C;
- CBF=
- cerebral blood flow;
- CI=
- confidence interval;
- Hb=
- hemoglobin;
- HBOC=
- hemoglobin-based oxygen carriers;
- LMA=
- leptomeningeal anastomosis;
- LVO=
- large vessel occlusion;
- MCA=
- middle cerebral artery;
- MCAO=
- middle cerebral artery occlusion;
- mRS=
- modified Rankin Scale;
- MT=
- mechanical thrombectomy;
- NBO=
- normobaric hyperoxia;
- NMDAR=
- NMDA receptor;
- NO=
- nitric oxide;
- RBC=
- red blood cell;
- RCT=
- randomized controlled trial;
- ROCK=
- rho-associated protein kinase;
- ROS=
- reactive oxygen species;
- SHRs=
- spontaneously hypertensive rats;
- SPG=
- sphenopalatine ganglion stimulation
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
- Received June 23, 2021.
- Accepted in final form September 3, 2021.
- © 2021 American Academy of Neurology
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