The future of stroke treatment

The concept of the therapeutic window of opportunity in ischemic neuronal i njury and understanding the necessity of well organized stroke services rev olutionized the management of acute ischemic stroke during the last years o f the second millennium. Thrombolysis with IV rt-PA within 3 hours from the onset of symptoms is an established therapy for selected patients. The cha llenge of stroke therapy at the outset of this millennium is how to transla te basic pathophysiologic evidence of ischemic neuronal injury into novel n europrotective therapies either independently or combined with thrombolysis . Great hopes are placed in identification of pivotal molecular events in i schemic brain tissue and design of effective pharmacological interventions to target them. Aggressive, invasive procedures are also being developed an d therapies such as intraarterial clot lysis, hemicraniectomy and mild hypo thermia may improve the bleakest outcomes associated with the most severe f orms of ischemic stroke, but their role must be rigorously evaluated. There is, however, no need to wait for future breakthroughs. The existing eviden ce strongly implies that good care of patients with stroke starts with orga nization of the entire stroke chain; from the prehospital scene, through th e emergency room, to the stroke unit. Without structured stroke services no pharmacological or intervening therapy is likely to improve the outcome of the patient with a stroke.