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Safety and Efficacy of Therapies for Acute Ischemic Stroke: A Review

This well-written paper addresses one of the most common clinical questions that neurologists and emergency room physicians face: What is the best treatment for acute ischemic stroke? Results of randomized clinical trials of drug therapies for acute ischemic stroke -- including intravenous and intra-arterial thrombolytic therapy, heparin, aspirin, and ancrod -- are summarized in the paper. The authors conclude that (1) intravenous thrombolysis with tissue plasminogen activator (t-PA) is safe and effective if administered within 3 hours after symptom onset; (2) intra-arterial thrombolytic therapy may improve outcome in patients with middle cerebral artery occlusion if administered within 6 hours of onset; and (3) aspirin offers moderate benefit in reducing recurrent stroke within 2 to 4 weeks of an acute stroke.

Comment: Although the authors provide an excellent summary of the most important clinical trials carried out over the last decade, a more detailed discussion of possible reasons for the conflicting results of the various IV thrombolytic trials would have been useful. Despite FDA approval of IV t-PA for acute ischemic stroke, this therapy is underused because many neurologists remain skeptical about its safety and efficacy (see N Engl J Med 1997; 337: 1309). If the authors had explained why one positive trial was sufficient to gain FDA approval, the information might have encouraged use of this important therapy. Ancrod has also been shown effective if administered within 3 hours of ischemic stroke in one trial (see JAMA 2000; 282:2395). A discussion of where ancrod fits into the treatment armamentarium would also have been useful.

— MI Chimowitz

Marc I. Chimowitz, MBChB, is Professor of Neurology, Emory University, Atlanta, GA.

Published in Journal Watch Neurology December 7, 2000

Citation(s):

Brott T and Bogousslavsky J. Treatment of acute ischemic stroke. N Engl J Med 2000 Sep 07 343 710-722.

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