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Objective : Thrombolytic therapy for acute ischemic stroke was implemented into clinical routine 4 years ago. Unfortunately, at present less than 2% of eligible patients receive thrombolytic therapy. We present an overview of all hitherto completed trials of intravenous and intraarterial thrombolytic therapy for carotid and vertebrobasilar artery storoke including recommendations for therapy and diagnostic procedures and their impact on patient selection and meta-analyses. New imaging techniques such as MRI diffusion- and perfusion-weighted imaging and their impact on patient selection are discussed. Finally, phase IV trials of thrombolysis in general and cost efficacy analyses are presented. Data Sources : We performed an extensive literature search not only to identify the larger and well-known randomized trials but also to identify smaller pilot studies and case series. Trials included in this review, among others, are the NINDS study, ECASS I and II, and ATLANTIS A and B, PROACT I and II and two large meta-analyses, including the Cochrane Library report. In addition, we inclue our own experience with more than 500 thrombolysis patients over the past 20 years where appropriate. Conclusion : Intravenous thrombolytic therapy with rt-PA has demonstrated a significant benefit and have proven to be safe for patients who can be treated within 3-6 hours after symptom onset. This benefit is at the cost of an increased rate of symptomatic intracranial hemorrhage without a significant effect on overall mortality. In general, the benefit of thrombolysis decreases and the risks increase with progressing time after symptom onset. Intraarterial thrombolytic therapy significantly improves outcome if administered within 6 hours after stoke onset. Vertebrobasilar occlusion has a grim prognosis and intra-arterial thrombolytic therapy to date is the only life-saving therapy that has demonstrated benefit with regard to mortality and outcome, albeit not in a randomized trial. New MRI-techniques may facilitate and improve the selection of patients for thrombolytic therapy. Presently, thrombolytic therapy is still underutilized because of problems with clinical and time criteria, and lack of public and professional education to regard stroke as a treatable emergency. If applied more widely, thrombolytic therapy may result in profound cost savings in healthcare and reduction of longterm disability of stroke patients.

Thrombolysis for the Treatment of Acute Ischemic Stroke