Intravenous thrombolysis for acute stroke

Until recently there was no specific therapy for stroke, but the recent publication of the National Institute of Neurological Disorders and Stroke(NINDS) t-PA for Acute Stroke Trial presents the first effective, specific therapy for stroke.1 In considering whether to apply thrombolysis to any given patient, the physician must consider the factors unique to each patient and the scientific literature regarding the therapy. We now review the literature that preceded the publication of the NINDS study to put the positive results into perspective. We selected papers for inclusion in our review in two ways. First, we collected the pivotal works known to one or more of the authors. Second, we performed a Medline retrieval for the years 1966 to 1996 using the search terms cerebrovascular disorders and human thrombolytic therapy, excluding references with the terms myocardial infarction or coronary angiography. We also excluded papers not written primarily in English. This search yielded 178 references. We carefully examined the titles and subject words. We eliminated 32 that appeared to be letters or editorials, 46 that appeared to be review articles with no original data, 10 that were case reports of one or a few patients, 23 that addressed the use of intra-arterial thrombolysis, and 53 that were concerned with other uses of thrombolysis such as removing intracerebral hematomas or preventing vasospasm. We retrieved, critically reviewed, and categorized the 14 remaining papers using the criteria listed in table 1. View this table: Table 1 Criteria used for categorizing publications reviewed here Rationale for cerebral artery thrombolysis. It has been assumed from the earliest writings on stroke and confirmed in recent studies employing vascular imaging techniques that most ischemic strokes result from vascular occlusion caused by thrombus.2,3 In a small minority of cases, ischemia may be caused by other mechanisms such as vasospasm. The …