Thrombolysis for Acute Ischemic Stroke: a New Paradigm

Modern day therapy of acute ischemic stroke is based upon intravenous thrombolysis, which has altered management of this potentially devastating disease. The urgent treatment of acute ischemic stroke must be of the same priority as the treatment of acute myocardial infarction. Specific networks must be established to ensure rapid transfer of stroke patients to designated hospitals that have the resources in place to deliver thrombolysis. Prior to the initiation of any treatment, diseases that mimic strokes must be ruled out. Prompt completion of computed tomography (CT) scanning should be performed to rule out hemorrhagic stroke and determination of the severity of the stroke using the various grading scales should be made. Recombinant tissue-plasminogen activator (rt-PA) is the only thrombolytic agent currently approved by the FDA for ischemic stroke treatment. It must be initiated within 3-4.5 hours of symptom onset. The extent of the difficulty in establishing the goals outlined above is evident from the observed low rate of thrombolysis. Even in the US, the proportion of stroke patients being thrombolysed does not exceed 3.5 %. This is primarily due to patient delayed presentation. However, the goal of initiating thrombolysis as soon as possible, to maximize the potential for benefit, should be strongly encouraged.