Acute stroke therapy 1981-2009.

This article includes a review of major intravenous and endovascular stroke trials, treatment options, and future aspects of acute stroke treatment in hemispheric and vertebrobasilar stroke. Since the invention of local intraarterial thrombolysis by Hermann Zeumer in 1981, acute stroke diagnostics and treatment have undergone dramatic improvement. This article addresses major topics in recent stroke treatment debates: optimization of patient selection, intravenous versus endovascular therapy, time window limitations, combined treatment with intravenous/intraarterial bridging therapies (intravenous/intraarterial recombinant tissue plasminogen activator [rtPA] bridging and intravenous glycoprotein IIb/IIIa inhibitor/intraarterial rtPA bridging) and modern endovascular treatment modes like percutaneous transluminal angioplasty (PTA)/stenting and mechanical thrombectomy devices. Modern acute stroke therapy networks should optimize their noninvasive diagnostic capacity to early identify candidates for endovascular therapy with rapid access to specialized neuroendovascular centers using standard protocols. The most promising approach in acute stroke treatment seems to be a combination of intravenous and endovascular revascularization procedure, combining early treatment initiation with direct clot manipulation and PTA/stenting in underlying stenosis with atherothrombotic occlusions. Further randomized studies comparing intravenous and endovascular treatment, mainly in the anterior circulation, have to be expected and need wide support of the neurologic and neuroradiologic stroke community.