Advances in the Acute Treatment and Secondary Prevention of Stroke

Stroke continues to be the leading cause of disability in industrialized nations and is one of the most difficult therapeutic challenges for physicians. Developments in neuroimaging and other diagnostic tests have improved our ability to identify and localize ischemic brain lesions and clarify their underlying etiologies. Until recently, however, physicians had no effective means of treating acute stroke. The success of thrombolytic therapy for acute stroke has invigorated clinical research aimed at identifying additional treatment options to expand and improve on intravenous thrombolysis. In the first part of this chapter, we focus on the large clinical trials of thrombolytic therapy for stroke and the clinical trial methodology that led to the success of the National Institutes of Neurologic Disorders and Stroke (NINDS) IV tPA trial. Since most stroke patients are not eligible for acute treatment, improving our ability to prevent stroke remains of critical importance. The second part of this chapter highlights the developments of specific antihypertensive, lipid-lowering, and antiplatelet agents that have expanded our armamentarium to diminish stroke risk. Looking to the future, we discuss the development of a new oral anticoagulant and ongoing challenges in the quest for a clinically effective neuroprotectant.