Revascularization therapy is pivotal to saving ischemic brain from infarction. Two major randomized trials of intravenous thrombolytic therapy have established clear clinical benefit, especially for strokes caused by small-vessel occlusion. Ischemic stroke caused by large-vessel intracranial occlusion carries higher morbidity, however, and intravenous thrombolytics are less capable of opening these large vessels. This observation makes a case for delivering thrombolytics directly into the clot, or simply removing the clot mechanically. Intra-arterial thrombolytic drugs have been shown to be effective for treating middle cerebral artery occlusions in a major randomized trial. In the past 2 years, a family of mechanical thrombectomy catheters designed to remove rather than dissolve the offending clot has received FDA clearance. Such devices offer alternative therapy to patients who cannot receive thrombolytics, and can also be used in combination with thrombolytics to safely restore cerebral perfusion. Mechanical techniques have not been directly compared with intra-arterial thrombolytic strategies, but these devices might be superior to thrombolytics within vessels with particularly high clot burden, such as the carotid terminus and the basilar artery. Comprehensive stroke centers are currently available in major metropolitan areas to treat stroke via intra-arterial means, and are likely to become 'hubs' to 'spoke' hospitals that are credentialed as primary stroke centers. This design will allow any patient timely access to state-of-the-art stroke treatment tailored to their needs.
