In search of real-world cerebroprotection: An institutional perspective and review of the literature

PurposeIntravenous (IV) thrombolysis and mechanical thrombectomy remain the only interventions shown to improve outcomes in acute ischemic stroke. This study evaluated the impact of commonly administered intraprocedural medications, each with putative neuroprotective mechanisms backed up by basic science literature, on outcomes in mechanical thrombectomy for acute ischemic stroke.Methods and ResultsA retrospective review of 284 patients utilizing univariate and multivariate analysis evaluated associations between administration of IV/intra-arterial (IA) tissue plasminogen activator (tPA), IV/IA heparin and IA verapamil as well as key outcomes: recanalization success, postoperative hemorrhage, and 90-day functional status. None of these medications were associated with favorable recanalization (TICI 2b/3) or functional outcomes (90-day modified Rankin score 0-2). IV tPA was associated with decreased rates of periprocedural hemorrhage (OR = 0.506, 95% CI [0.255-0.980], <i>p</i> = 0.046). Successful recanalization (OR = 2.22, 95% CI [1.03-.4.98], <i>p</i> = 0.046), presence of any hemorrhage (OR = 0.27, 95% CI [0.14-0.51], <i>p</i> = <0.001), lower age and lower NIHSS, were predictive of good outcome. Heparin was associated with an increased risk of hemorrhage (OR = 1.90, 95% CI [1.11-3.21], <i>p</i> = 0.02) and poorer outcomes (OR = 0.56, 95% CI [0.35-0.91], <i>p</i> = 0.018) in univariate analysis, with a similar trend in multivariate analysis (OR 0.57, 95% CI [0.30-1.06] <i>p</i> = 0.079).ConclusionAlthough several medications with basic science support for cerebroprotective effects are frequently administered during thrombectomy, the most effective strategies for improving functional outcomes remain prompt, successful recanalization and minimizing hemorrhage. With recanalization rates exceeding 80% and primarily determined by mechanical factors, targeting hemorrhage reduction appears critical for further outcome improvements. Evidence linking post-ischemic hemorrhage to blood-brain barrier disruption offers future avenues for research into interventions for this potentially reversible process.