Massive Stroke

There have been significant developments in the diagnosis and management of ischaemic stroke.   This started with trials showing a benefit for decompressive craniectomy after a malignant hemispheric stroke in patients under 60 undergoing surgery within 48 hours.   The evolution of CT and MRI have enabled us to better image not only the ischaemic core of the stroke, but also the surrounding hypo-perfused brain at risk of ischaemic death; the penumbra. CT and MR angiography now allow rapid, non-invasive detection of occlusions in the major neck and intracranial arterial vessels.  These techniques are key to the appropriate selection of patients for therapeutic interventions aiming at rapid and effective arterial recanalisation to restore blood flow. Intravenous thrombolysis with rt-PA is effective if given early and no later than 4.5 hours. The benefit of intravenous thrombolysis for patients with severe stroke due to large artery occlusion is limited but these patients may be candidates for mechanical thrombectomy. Since 2014, several trials have confirmed the effectiveness of thrombectomy for patients with anterior circulation artery occlusion with a number needed to treat of less than 3 for improved functional outcome. Two recent trials have also shown that in selected patients, the benefit of thrombectomy extends to at least 24 hours, increasing the number of patients eligible to receive this treatment.   The rate of intravenous thrombolysis remains low in many Australian centres, especially in regional areas and only a few metropolitan centres provide a thrombectomy service.  With the recent expansion of the time window, the logistics of patients being transferred to these centers has improved but good selection of patients with advanced imaging is a prerequisite to ensure that health resources are used efficiently.   There is a need to improve health services to better manage stroke patients in Australia and worldwide. This has the potential to improve outcome for stroke victims.