The Now and Tomorrow of Ischemic Stroke Treatment

The last decade has witnessed a number of major developments in the field of stroke. A major breakthrough in the treatment of ischemic stroke was attained by the demonstration of improved functional outcomes with intravenous tissue plasminogen activator therapy in the hyperacute period. Recent efforts of pre-hospital thrombolysis facilitated by the use of specialized stroke ambulance systems and newer generation thrombolytics provide promising results in terms of optimizing the benefit obtained from intravenous thrombolysis. These advances, together with successful results observed by endovascular recanalization, especially by the use of thrombectomy devices, unambiguously demonstrate that the penumbra concept (presence of a salvageable ischemic brain tissue) is valid. Despite these encouraging developments, other approaches like neuro-glial protection or restoration have not been so successful in patients with acute ischemic stroke. Nonetheless, there is still hope for these therapies, especially if clinical and radiological algorithms are developed for appropriate patient selection and the recanalization is supplemented by measures aiming neuroprotection and restoration of blood flow not only at the arterial but also microcirculatory level. As for secondary prophylaxis of ischemic stroke, the availability of new anti-platelet and anti-coagulant agents combined with the progress attained in risk factor control has led to an impressively significant reduction in stroke related mortality and morbidity over the last decades.

Keywords: Anticoagulants, Antiplatelet agents, Drug treatment, Endovascular recanalization, Ischemic stroke, Microcirculation, Neuroprotection, Penumbra, Thrombolytics.