Table.

Summary of adjunctive and alternative approaches to reperfusion therapy in acute ischemic stroke.

Category	Agent or Device	Description	Current phase of testing
Combinatory approaches	tPA + direct thrombin inhibition tPA + low molecular weight heparin tPA + acetylsalicylic acid fibrinolytic (tPA or reteplase) + GPIIb/IIIa inhibitors Sonothrombolysis (tPA + therapeutic ultrasound)	Agents combined to enhance the efficacy of fibrinolytics, prevent arterial re-occlusion and/or improve microcirculatory flow.	II None current III II II & III
Novel Systemic Thrombolytic or Defibrinogenating agents	Tenecteplase (TNK) Desmoteplase Plasmin Ancrod	Agents tested in either: an extended time window from symptom onset (i.e., >4.5 hours) head-to-head comparison with intravenous tPA	None, recently completed Phase II Phase III I/IIa None current
Endovascular medical or mechanical reperfusion treatments	Interventional Management of Stroke-3 (IMS-3) MR and Recanalization of Stroke Clots Using Embolectomy(MR RESCUE)	Direct intra-arterial approach allows for local lytic application and greater rates of arterial recanalization.	III II
Non-invasive or minimally-invasive methods to augment cerebral blood flow and alleviate intracranial blood flow steal	External counterpulsation Non-invasive ventilatory support in stroke patients with steal Sphenopalatine ganglion (SPG) stimulation Partial aortic occlusion	Device applies one hour of full-pressure (or sham) external cuff inflation around the lower extremities timed with the patient’s electrocardiogram. Application of bi-level ventilation improves intracranial steal in documented arterial occlusion. Stimulation of SPG increases cerebral blood flow. Abdominal intra-aortic catheter partially obstructs blood flow increases cerebral blood flow.	I None current III None, recently completed Phase III