Recanalization and Stroke Outcome

Since work in the early 1980s suggested that acute recanalization of an occluded brain-supplying artery was feasible, a series of small uncontrolled and controlled studies supported the notion that recanalization could improve the outcome of ischemic stroke.1 That early work paralleled similar successful efforts to achieve recanalization of occluded coronary arteries with plasminogen activators in patients presenting acutely with myocardial ischemia. The very nature of the outcomes of ischemic cerebrovascular disease, that demise does not reflect the evolution of brain injury, different from myocardial ischemia, has required rapid, readily applicable reproducible assessments that include neurological deficits and types and grades of disability. These reflect the arterial supply of the brain and its regional specialization of function: motor skills, sensory perception, speech, association areas (mostly silent), cognition, autonomic function, and countless others. This complexity of functions vulnerable to focal ischemia, the variations in arterial supply from patient to patient, and differences in occlusion location within a single brain-supplying artery ensure that outcomes can be quite heterogeneous. From the outset, it has been recognized that instruments for outcome measures must capture these variables. To date, the most versatile instruments reflect functions that can be readily detected by the neurological examination. But, obtaining information regarding arterial supply and occlusion location together in the acute setting requires formal imaging techniques. This information cannot be exactly deduced by the neurological examination alone.Article p 2660 The hypothesis that recanalization of an occluding thrombus in the symptom-producing cerebral artery could improve neurological function (reduce disability) became testable when the fibrinolytic approach was applied early enough to allow restoration of flow but not substantially increase the risk of hemorrhagic transformation.2,3 Mori et al4 and Yamaguchi et al5 both demonstrated a relationship between acute recanalization documented by cerebral angiography and neurological outcome. In those …