Does intra-arterial thrombolysis have a role as first-line intervention in acute ischaemic stroke?

Minimization of the clinical impact of acute ischaemic stroke depends largely on prompt restoration of blood flow to underperfused regions of the brain. Intravenous thrombolysis (IVT) is currently the first-line intervention for acute ischaemic stroke, with proven efficacy in randomized controlled trials. There are several major limitations associated with IVT, in particular, the relatively poor outcomes in large artery occlusions. A major emerging modality in acute stroke management is intra-arterial thrombolysis (IAT), whereby clot-retrieval or thrombolytics are applied under angiographic guidance to the site of the clot. Strong arguments exist for the use of IAT as first-line ischaemic stroke management in preference of IVT, especially with large intracranial artery occlusion. Despite these arguments, the lack of data from randomized controlled studies in IAT means that it is appropriate to continue the current practice of IVT as first-line treatment for the majority of acute ischaemic strokes at this stage. Advanced neuroimaging techniques, in particular a 'multimodal' computed tomography (CT) approach combining non-contrast CT, CT angiography and perfusion CT, may serve as a valuable triage tool for patient selection. Ongoing research is required in endovascular approaches to stroke; in particular, randomized controlled trials with a focus on clinical outcomes and tackling the inherent delays between symptom onset and treatment.