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(Stroke. 2009;40:2615.)
© 2009 American Heart Association, Inc.

Controversies in Stroke

IV and IA Thrombolytic Stroke Strategies Are Complementary

Geoffrey A. Donnan, MD, FRACP Stephen M. Davis, MD, FRACP

From the Royal Melbourne Hospital, University of Melbourne, Parkville, Vic, Australia.

Correspondence to Stephen Davis, Controversies Editor, Stroke, Royal Melbourne Hospital, University of Melbourne, Parkville Vic Australia 3050. E-mail stephen.davis@mh.org.au

Key Words: thrombolytic RX • TPA

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

This is a classical confrontation in stroke medicine between pragmatic evidence-based therapies for the masses versus cutting-edge biologically plausible interventions that would be restricted to comprehensive stroke centers. Despite the accumulating evidence that IV therapy is less effective in patients with large clot burdens, such as ICA occlusion, there is still no level 1 evidence that IA therapy is superior to IV within 3 hours.

For the foreseeable future, we agree with Lindley that the first priority should be to rapidly increase the rate of use of standard IV tPA in stroke unit settings worldwide, given within 3 or probably now 4.5 hours.^1,2 The scale of this challenge cannot be understated. Further, the issue of small vessel disease cannot be ignored, where an IV approach seems logical and may represent up to 20% of all ischemic strokes.

However, in parallel, we would strongly support the view of Moonis that even more effective means of clot dissolution must be aggressively pursued. We should not forget the cardiac roadmap, where IV thrombolysis was first proven, then increasingly replaced by acute mechanical intervention in the cath laboratory after superiority was shown in clinical trials.³ Even now, some expert stroke centers routinely use IA thrombolysis in the setting of a highly-organized system in partnership with an interventional team.⁴ This is supported by PROACT 2,⁵ which demonstrated the benefits of IA thrombolysis out to 6 hours, although this approach has not been licensed in the absence of a confirmatory trial. Furthermore, some centers use a . . . [Full Text of this Article]