Responses to acute stroke: beyond urgent imaging and systemic thrombolysis, where to now?

Stroke medicine has changed substantially in the last decades and there is cautious optimism in the stroke community that acute interventions will continue to improve. Our 'wish list' includes evidence-based treatments for ICH, targeted reperfusion therapy and rescue therapy for those who fail to reperfuse with conventional treatment, all of which would be augmented by potential neuroprotectant strategies, such as therapeutic hypothermia. These goals are ambitious but not unachievable and success will depend on quality clinical trials comparing novel strategies to standard care (and not other unproven strategies), along with continued major investment in stroke services. It was a challenge to introduce thrombolytic therapy across the UK and it will be orders of magnitude more difficult to routinely deliver novel imaging techniques, minimally invasive neurosurgical techniques and catheter-based thrombectomy should they prove to be effective.