Northeast Florida Medicine
Vol. 66, No. 3 2015
47
Endovascular Neurosurgery
obtainCTA andCTperfusion studies.This enables clinicians
to exclude a hemorrhagic event and determine whether there
is salvageable brain tissue based on perfusion parameters
while concomitantly locating a target vessel for mechanical
thrombectomy. It is important to stress that the neurological
exam is also a critical component of stroke management and
serial scores on the NIHSS (National Institutes of Health
Stroke Scale) are routinely obtained before and after stroke
therapies are initiated, including medical (tPA) or surgical.
In general terms, a decrease in the NIHSS score is an indi-
cation of successful treatment and recanalization.
Moreover, not every hospital can or should perform en-
dovascular stroke therapy, thus creating major implications
for triaging decisions by emergency medical services. Futile
measures that may delay access to a comprehensive stroke
center are not in the patient’s best interest to say the least.
The current state of endovascular technology may provide
the tools to reopen an occluded middle cerebral artery but
real clinical benefit is time-dependent and as the volume
of infarct core increases, so does the risk of hemorrhagic
conversion after recanalization, a devastating complication
of stroke intervention. Based on the current standard of
care for stroke patients, triage decisions should take into
consideration whether there is large vessel occlusion and
administration of IV tPA should no longer dissuade phy-
sicians from referring patients to the neurointervention
suite.
8,9,10,11,12
These decisions can be facilitated by creating
treatment algorithms and educating health care providers. Si-
multaneously, technological advancements such as telestroke
andmobile stroke units gainedmomentumrecently and have
the potential to revolutionize stroke treatment by extending
the reach of excellence centers to smaller communities and
underserved areas. Ultimately, the decision to undertake
endovascular thrombectomy should be made jointly by a
multidisciplinary team including, at a minimum, a stroke
physician and an experienced specialist in neurointerven-
tion. There is now a great deal of enthusiasm regarding the
future of stroke treatment and the real winners of this new
era are the patients who now have better than ever chances
of overcoming the odds.
v
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