Purpose of review
Stroke thrombolysis is in the process of moving from academic centers into community-based standard therapy in experienced centers. Recently published data on patient selection, imaging and other technical or organizational advances are reviewed in order to improve the safety and efficacy of stroke thrombolysis and identify areas in which more study is needed.
During the past year, several open series were published on the application of thrombolysis in community-based settings, which have mostly reproduced the outcome described in randomized, placebo-controlled recombinant tissue plasminogen activator cohorts. New information has been produced to identify the clinical parameters that are associated with good and adverse outcomes after stroke thrombolysis. Elevated blood glucose decreases the likelihood of a good outcome and increases that of cerebral hemorrhagic change, but the effect of early glucose reduction needs to be investigated. Non-contrast computed tomography still prevails as the standard imaging method in patient selection, but computed tomography angiography can be added within a reasonable time to furnish vascular diagnosis. Perfusion-weighted imaging is used to quantify the fraction of brain tissue salvaged by intravenous thrombolysis, and may be used in the future to select patients with still viable penumbral brain tissue, even beyond a 3-h time-window, if efficacy can be proved.
Thrombolysis with recombinant tissue plasminogen activator is well tolerated and effective within 3 h of symptoms, and new trials will determine if extension of this time-window or new target populations for thrombolysis, such as children with stroke, can be substantiated. An unfinished task remains in the education of health personnel; imperatives stemming from pathophysiology need to penetrate attitudes on acute stroke at all levels before acute therapies such as thrombolysis can have an impact on stroke outcome in general.