Stroke therapy — time for a clinical breakthrough

Abstract

Abstract. Attempts to limit brain infarct size and improve clinical outcome in patients with acute ischaemic stroke have focused on the restoration of blood flow and neuroprotection. Haemodilution to improve blood flow in the low‐flow zone (penumbra) surrounding the core of the infarct has not been successful in clinical trials. No consistent effect of prostacyclin has been documented. In contrast, beneficial effects of thrombolytic agents (streptokinase, urokinase or t‐PA) have been reported in animal models of stroke and in small series of patients with ischaemic stroke. There is a substantial risk of intracerebral bleeding that increases with delay from onset of symptoms to start of treatment. Large‐scale, placebo‐controlled trials of intravenous rt‐PA and streptokinase are ongoing. Interventional neurovascular techniques have been successfully applied in patients with acute embolic occlusion of extracranial or intracranial arteries, and these procedures are now ready for randomized trials.Amongst neuroprotective agents, calcium‐channel blockers have been most extensively studied in clinical trials, but no convincing benefits have been shown. Scavengers of free radicals and inhibitors of presynaptic glutamate release and glutamate‐receptor blockers reduce brain infarct size in laboratory animals and are now being investigated in clinical trials.To fully exploit, in routine clinical practice, a breakthrough in reperfusion and/or neuroprotection therapy, a drastic reorganization of the management of stroke patients before and immediately after arrival to hospital will be needed.