title: Improving reperfusion therapy for acute ischaemic stroke.
abstract: BACKGROUND
  The first generation of clinical reperfusion treatment, intravenous (IV) fibrinolysis with tissue plasminogen activator (tPA), was a transformative breakthrough in stroke care, but is far from ideal.
  
  
  OBJECTIVE
  TO survey emerging strategies to increase the efficacy and safety of cerebral reperfusion therapy.
  
  
  METHODS
  Narrative review.
  
  
  CONCLUSIONS
  Innovative IV pharmacologic reperfusion strategies include: extending IV tPA use to patients with mild deficits; developing novel fibrinolytic agents (tenecteplase, desmetolplase, plasmin); using ultrasound to enhance enzymatic fibrinolysis; combination clot lysis therapies (fibrinolytics with GPIIb/IIIa agents or direct thrombin inhibitors); co-administration of MMP-9 inhibitors to deter haemorrhagic transformation; and prehospital neuroprotection to support threatened tissues until reperfusion. Endovascular recanalisation strategies are rapidly evolving, and include intra-arterial fibrinolysis, mechanical clot retrieval, suction thrombectomy, and primary stenting. Combined approaches appear especially promising, using IV fibrinolysis to rapidly initiate reperfusion, mechanical endovascular treatment to debulk large, proximal thrombi, and intra-arterial (IA) fibrinolysis to clear residual distal thrombus elements and emboli.
authors.affiliation: Stroke Center and Department of Neurology, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA. jsaver@ucla.edu
authors.forename: J L
authors.initials: JL
authors.lastname: Saver
mesh_terms: D000208:Acute Disease; D002545:Brain Ischemia / Q000188:drug therapy*; D005342:Fibrinolysis; D006801:Humans; D007262:Infusions, Intravenous; D020521:Stroke / Q000188:drug therapy*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000627:therapeutic use*
chemical_list: D010959:Tissue Plasminogen Activator