Page 9 - BH-3-3

Brain & Heart

REVIEW ARTICLE
Expanding boundaries in stroke treatment: New

horizons in revascularization strategies and
critical decision-making

Paolo Amisano* , Marco Andrighetti , and Danilo Toni

Department of Human Neuroscience, Sapienza University of Rome (Faculty), Rome, Italy
(This article belongs to the Special Issue: Correlation Between Ischemic Heart Disease and
Cerebrovascular Disease. The clinical practice messages from the Aosta Meeting in June 2024)

Abstract

Ischemic stroke is one of the leading causes of mortality and long-term disability
worldwide, emphasizing the need for rapid and effective acute management.
Revascularization therapies are critical to this strategy, demanding swift intervention.
Intravenous thrombolysis (IVT) with alteplase (ALT) was traditionally recommended
within 4.5 h from symptom onset for acute ischemic stroke (AIS) patients. However,
landmark studies, such as ECASS IV, EXTEND, and EPITHET have demonstrated that IVT
may be extended up to 9 h in select patients, identified through perfusion imaging
with computed tomography or magnetic resonance imaging, enabling differentiation
of viable, at-risk brain tissue in the ischemic penumbra from the infarct core. This
*Corresponding author:
Paolo Amisano allows treatment in cases with favorable “mismatch” profiles, Similarly, endovascular
(paolo.amisano@uniroma1.it) procedures for large vessel occlusions (LVOs) were initially recommended within 6 h,
Citation: Amisano P, Andrighetti M, but trials, such as DEFUSE-3 and DAWN have established efficacy for thrombectomy
Toni D. Expanding boundaries in up to 16 – 24 h from the last known well time, using perfusion imaging to guide
stroke treatment: New horizons in patient selection. These advancements prioritize tissue viability over rigid temporal
revascularization strategies and
critical decision-making. Brain & thresholds. Despite significant progress, optimal revascularization strategies for AIS
Heart. 2025;3(3):6683. remain uncertain in complex clinical contexts, such as posterior circulation strokes,
doi: 10.36922/bh.6683 large infarct core AIS, distal vascular occlusions, and mild clinical deficit LVO-related
Received: November 29, 2024 AIS. Recent research aims to address these gaps, expanding reperfusion criteria and
exploring new thrombolytic agents with potential benefits over ALT. Collectively,
Revised: January 10, 2025
these studies aim to refine and broaden therapeutic criteria, improving outcomes for
Accepted: January 21, 2025 a wider AIS patient population.
Published online: February 6,
2025
Keywords: Acute ischemic stroke; Revascularization therapies; Intravenous thrombolysis;
Copyright: © 2025 Author(s). Endovascular thrombectomy; Reperfusion criteria
This is an Open Access article
distributed under the terms of the
Creative Commons Attribution
License, permitting distribution,
and reproduction in any medium, 1. Introduction
provided the original work is
properly cited. Acute ischemic stroke (AIS) remains a leading cause of death and long-term disability
Publisher’s Note: AccScience worldwide, stressing the critical need for effective acute interventions. Revascularization
Publishing remains neutral with therapies have revolutionized the management of AIS by shifting the focus from
regard to jurisdictional claims in
published maps and institutional supportive care to targeted reperfusion strategies aimed at restoring cerebral blood flow,
affiliations. salvaging ischemic brain tissue, and improving clinical outcomes.

Volume 3 Issue 3 (2025) 1 doi: 10.36922/bh.6683