Advances in stroke: emerging therapies.

O ver the past 2 years, the results of large clinical trials have fundamentally changed the clinical practice of stroke care in several different ways. Perhaps the greatest advances have occurred in stroke prevention, where we now have a wider array of anticoagulants to reduce the risk of stroke in patients with atrial fibrillation and we have confirmation from 2 large studies that medical therapies are more effective at stroke prevention than endovascular and surgical procedures for patients with intracranial atherosclerotic disease and internal carotid occlusion, respectively. However, new technological improvements have advanced endovascular techniques for acute isch-emic stroke (AIS) to the point where we are on the verge of determining whether intra-arterial treatments may actually improve outcome. We discuss the highlights of several important articles during the past 2 years that have advanced the field in emerging therapies for stroke. Although no major advances have yet led to the approval of novel thrombolytic agents for AIS, the long awaited placebo-controlled IST-3 trial on IV t-PA for AIS was finally completed. IST-3 is the largest thrombolysis trial ever involving >3000 patients, confirming once again the benefits of IV t-PA and that, in unselected patients, alteplase is most effective in the 3-hour time window. 1 The study supports the long-held notion that selected criteria are needed to identify patients who would benefit in time windows beyond 3 hours from symptom onset. In this respect, Parson et al, 2 conducted a phase IIB trial in which alteplase was compared with tenecteplase in patients who had a large artery occlusion and a perfusion lesion at least 20% greater than the infarct core on computed tomographic perfusion. Tenecteplase was associated with better reperfu-sion and better clinical outcomes compared with alteplase. 2 This study not only supports the use of advanced imaging to identify patients likely to benefit from intravenous thrombo-lytic agents but also raises much hope that agents better than alteplase may be on the near horizon for clinical use in AIS. Because of the limitations of IV t-PA for large artery occlu-sions, mechanical devices are widely used as alternative treatment options to achieve recanalization and reperfusion, often with variable results. Higher rates of recanalization using these devices have not consistently translated to better outcomes, necessitating the development of next-generation equipment. The application of stent retrievers represents a technological advancement in endovascular approaches for large artery occlu-sion. In the SWIFT and TREVO trials, 3,4 …