Intravenous Thrombolytic Therapy in Acute Stroke

Abstract

The article reviews the experimental basis of thrombolytic therapy, and summarizes the results of the recent trials of thrombolysis. Five large clinical trails have evaluated intravenous thrombolytic therapy for the treatment of hyperacute (< 6 h) stroke. Three of these studies were negative, one was equivocal, and one was strongly positive. The failure to demonstrate efficacy definitively in four of these trials may be related to a number of methodological factors, including the type and dose of drug administered, the timing of drug administered, and the method of patient selection for treatment.

The NINDS recombinant tissue plasminogen activator (rt-PA) study showed that thrombolytic therapy can be of substantial benefit when administered within 3 h of stroke onset using strict patient selection criteria and rt-PA is now FDA approved for treatment of acute stroke. However, the risk of clinically significant bleeding is elevated. To achieve the favorable risk/benefit ratio demonstrated in the NINDS trial, patients must be screened by experienced clinicians for contraindications to thrombolysis and the acute computerized tomography (CT) brain scan must be carefully, evaluated for radiographic features that increase the risk of cerebral hemorrhage. Guidelines for the use of rt-PA are provided, as well as insights into future thrombolytic treatment strategies.