BNA 2023 | Next steps in acute stroke treatment

Most people are familiar with how acute ischemic stroke is treated. There are two treatment options: that’s intravenous thrombolysis, meaning pharmacological clot dissolver by just injecting an IV drug, and the other option is mechanical clot removal and that’s going with the tiny catheter through the groin all the way up to the brain and then kind of pulling out the blood clot that’s blocking the blood vessel, so to speak. And in both these areas, there have been quite some advancements in the last couple of years. So when talking about the pharmacological side, newer and better thrombolytic agents have been developed and also currently in the making are some alternative thrombolytic agents with different mechanisms of action. So right now we’re using tissue plasminogen activators, meaning drugs that kind of split fibrinogen, so that activate plasmin and then split fibrinogen. So it kind of tackles the fibrin fibrinogen component of the clot and the newer agents, for instance, are able to dissolve neutrophil extracellular traps and different components of the blood clot. So that’s the new things going on in the world of IV thrombolysis.

In terms of endovascular treatment, now we’re able to mechanically remove blood clots, which is way more efficient than pharmacologically dissolving them, meaning that we can achieve reperfusion of the ischemic brain tissue in many, many patients. And that kind of has enabled us to use cerebroprotectants and cerebroprotectants are agents that delay ischemia tolerance of the brain so infarcts can be postponed but they cannot be avoided. Meaning we can buy ourselves time to treat patients and that’s only possible if ultimately reperfusion is possible. So if the vessel is opened and endovascular treatment has kind of enabled us to achieve reperfusion consistently. So that’s why now there’s a lot more research going on in terms of cerebroprotection, and whereas before endovascular treatment has become standard of care in 2015 or so it was kind of a moot topic because you couldn’t achieve reperfusion very reliably. So cerebroprotection was not an issue. So in terms of endovascular removal, cerebroprotections are I think the most exciting field right now where also neuroscientists could kind of contribute or look into alternative or additional therapeutic options for acute stroke patients.