Thrombolytic therapy of acute stroke.

Case 1. A 65-year-old right-handed man with no history of heart disease presented to the emergency department with right-sided weakness and an inability to speak. His wife last saw him well 1 hour before his arrival. His ECG showed atrial fibrillation with a ventricular response of 100 bpm; his blood pressure was 175/ 88 mm Hg. He was alert, but he did not produce or comprehend speech. He did not blink to a threat presented in the right visual field. There was weakness of the right lower face and of the right arm and leg (National Institutes of Health Stroke Scale score, 15 of a possible 42). A noncontrast cranial computed tomography (CT) image showed no hemorrhage and no signs of early ischemia. Case 2. A 39-year-old woman in good general health was found mumbling incoherently with left-sided weakness. She had been well minutes before. She was brought to a local hospital where she was noted to neglect her left personal space and to have left homonymous hemianopsia, rightward eye deviation, left lower facial weakness, and left arm and leg weakness (National Institutes of Health Stroke Scale score, 17). A head CT showed no evidence of hemorrhage or early ischemia, and she was given intravenous tissue-type plasminogen activator (tPA) before transfer to a comprehensive stroke center for consideration of intra-arterial therapy. On arrival at the receiving facility shortly after completion of the tPA infusion, her examination had not improved. A noncontrast head CT showed some loss of gray-white differentiation in the right parietal lobe (Figure 1A) and posterior insular cortex, and a CT angiogram showed abrupt cutoff of the right middle cerebral artery stem (Figure 1B). A conventional angiogram confirmed the right middle cerebral artery stem occlusion (Figure 1C). The therapy of acute stroke has advanced dramatically over the last 15 years with the use of intravenous tPA and intra-arterial catheter-based revascularization techniques. At their best, these therapies allow the physician to arrest the progression of what would otherwise become a devastating stroke. Yet, the majority of patients with stroke still do not benefit from these therapies either because the brief time window of benefit and safety imposes administrative, medical, and logistical demands that have not been met or because, even when applied early, these therapies are effective in only some patients. Therefore, it is important that we expand access to and implement currently available therapies as efficiently as possible. In addition, we must continue to refine these therapies and to develop new ones. This review provides a focused update on the current therapy of acute stroke.