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(Stroke. 2004;35:911.)
© 2004 American Heart Association, Inc.

Original Contributions

Editorial Comment—More Than One Way to Lyse a Clot

Scott E. Kasner, MD

An extract of the first 250 words of the full text is provided, because this article has no abstract.

Intravenous tissue plasminogen activator (IV tPA) is generally effective in a wide range of patients with acute stroke,^1,2 and can be administered in nearly any acute care hospital, at least theoretically, because no advanced resources are necessary.³ IV tPA is therefore the best option for most patients. However, one of the major lessons learned from the pivotal NINDS trial¹ establishing the efficacy of IV tPA for acute stroke was that, despite aggressive therapy, the majority of patients were still left disabled or dead. New strategies are desperately needed to improve outcome. IV tPA is essentially a "one size fits all" treatment, based only on clinical presentation and CT of the brain, not visualization of the target thrombus. Recanalization rates of major occlusions may be relatively low, possibly <25%. Further, up to 20% of patients have clinical deterioration following improvement with IV tPA, most often due to reocclusion,⁴ though collateral failure, reperfusion injury, edema, and other explanations have been proposed.⁵ Clinicians are therefore left to ask, "What more could be done?"

Intra-arterial (IA) thrombolysis is effective,⁶ but remains an unapproved, off-label treatment for acute stroke. Potential advantages of IA thrombolysis include direct visualization of the acute large vessel thrombus, the ability to individualize the dose and location of drug delivery based on specific features of the clot, and possibly more complete clot lysis. Recanalization, the most critical determinant of good clinical outcome,⁶ can be verified during IA treatment as a marker of procedural success. Unfortunately, IA thrombolysis takes much longer to . . . [Full Text of this Article]