New treatments in acute ischemic stroke.

Since the advent of intravenous thrombolytic therapy with recombinant tissue plasminogen activator (tPA) for acute ischemic stroke, there has been a marked change in our management approach to patients with acute ischemic stroke. Although the major part of our focus in treating patients with stroke remains prevention of complications post-stroke and reduction of stroke recurrence, there is a paradigm shift to immediate "clot" lysis. This concept is being actively promoted through certification of institutions as stroke centers in order to increase the number of patients with stroke treated in an ultra-rapid fashion. However, options for acute treatment remain limited. Other than aspirin, the only US Food and Drug Administration-approved agent for acute ischemic stroke is intravenous tPA. Some physicians treating patients with acute ischemic stroke still frequently use heparin and low-molecular-weight heparinoids, but there are no firm data to support routine use of this drug class. However, a number of new lytic agents and strategies are being pursued. Some of these treatments, such as intra-arterial chemical thrombolysis or mechanical intra-arterial thrombolysis, are available only at specialized stroke centers. In addition, new antithrombotic agents are being studied. Drugs that can rescue neurons from impending hypoxia-ischemia cell death represent the "holy grail" of acute stroke therapy. To date, these "neuroprotectant" strategies have been unsuccessful, although this concept remains under active investigation in animal and human trials.