IA Stroke Therapy: Why and Why Not

graphi cally to have alterial occlusions, the clinical histOIY and exam can be relied upon to detect appropriate patients for rr-PA. The Furure of Stroke The approva l of rr-PA as the first accepted treatment fo r acute stroke is only the beginning. The limitation of the 3-hour window reduces the feasib il ity of adm inistering the drug to all patients who present with stroke symptoms. The first step towards improving stroke treatment lies within education of the general population and health care providers. Stroke has to be thought of as an emergency that requires immediate medica l intervention. Most patients do not recognize the symptoms of stroke. It is crucial that the genera l population identify the warning signs of stroke and associate the signs with a "brain attack." The idea of administering a "stroke cocktail" in the treatment of acute stroke is not far from reality. The abil ity to preserve viable brain tissue in the area of the infarction is the concept behind neuroprotection. Neuroprotection can be used to extend the therapeutic window so that a greater nu mbers of patients ca n be treated. It might also offer some benefit in the treatment of hemorrhagic stroke. By attacking the mecharusm of stroke at various sites, the likelihood of reducing the degree of deficits and improving the functiona l outcome is greater.

References 1. Adams HP Jr, Brott TG, Furlan A), et al. Guidelines

for thrombolytic therapy for acute stroke: a supplement to the gUidelines for the management of patients with acute ischemic stroke. Circulation ] 996; 94,1167. 2. Brott TG, Haley EC Jr, Levy DE, Urgent u,erapy for stroke: parr 1: pi lot study of tissue plasminogen activator administe red within 90 mi nutes. Stroke 1992; 23,632. 3. caplan L, Mohr JP , Kistler JP, Korosue K. Sho uld thrombolytic therapy be the first-line treatment for acute ischemic s(Ioke? thrombolysis--not a panacea for ischemic stroke. N Engl ] Med 1997; 33n309. 4. Collen D, Strassen JM, Marafino BJ Biological properties of human tissue-type plasminogen activator obrtained by exp ression of recombinant DNA in manuna lian cells. J Pharmacol Exp Ther ]984; 231: 146. 5. del Zoppo G. Acute stroke: on the threshold of a therapy' N Engl J Med 1995; 333,1632-1633. 6. del Zoppo G, Copeland BR, Waltz TA, Zyroff J, Plow EF, Harker LA. The beneficial effect of intra carotid urokinase on acute stroke in a baboon mode l. Stroke 1986; 17,638. 7. del Zoppo G, Poeck K, PeSSin MS, ct al. Recombi-

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nant tissue plasminogen activator in acute thrombotic and embolic stroke. Ann Neurol ]992; 32:78. 8. Feldmann E, Gordon N, Brooks )M, et al. Factors associated with early presentation of acu te stroke. Stroke 1993; 24,1805. 9. Hacke W, Kaste M, Fieschi C, et al. Randonllsed double-blind pla cebo~con tro ll ed trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Lancet 1998; 352, 1245. 10. Haley EC, Brott TG, She ppard GL, et al. Pilot randomized trial of tissue plasminogen activator in acute ischemic stroke. Stroke ]993; 24:1000. 11. Haley ECJr, Levy DE, Brott TG, et al. Urgent therapy for stroke: part II: pilot study of ti ssue plasminogen activator administered 91-]80 minutes from onset. Stroke 1992; 23,641.

]2. NINDS rt-PA Stroke Srudy Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333, 1581. 13. NINDS TPA Stroke Study Group. Generalized efficacy of rt-PA for acute stroke. Stroke 1997; 28,2119. 14. ]{jngelstein EB, Biniek R, WeUler C, Ammeling B, Nolte PN . Type and extent of hemispheric brain infarctions and clinical outcome in early and delayed middle cerebral artery recanalization. Neurology 1992; 42,289.

15. Sussman B, Fitch T. Thrombolysis with fibrinolysin in ce rebra l arterial occlusion. JA1v1A 1958; 167:1705. ]6. The E(ASS Study Group. European cooperative acute stroke study (ECASS) rt-PA-thrombolysis in acute stroke study design and progress report. EUr J Neu ro l 1995; 1.213. 17. von Kummer R, Hacke W. Safety and efficacy of intravenous tissue plasminogen activator and heparin in acute middle cerebral artery stroke. Stroke 1992; 2H46. ]8. Ziv in JA , Fisher M, DeGirolami U, Hemenway CC, Stashak KA. Tissue plasminogen activator reduces neurolog ical damage aner cerebral embolism. Science 1985; 230,1289.

12:55 pm IA Stroke Therapy: Why and Why Not Brian Berger, MD

Radiology Consultants Nashville, Tennessee 1:20 pm

IA Stroke Therapy: The Brain Plumbing How-to Guide Gary M. Nesbitt, MD Oregon Health Sciences University

Portland, Oregon