IA thrombolysis demonstrates significant recanalization efficacy compared to placebo and IV rt-PA for patients with large vessel occlusions. However, IA thrombolysis has not been shown to be superior to IV rt-PA in IV rt-PA eligible patients. IA stroke thrombolysis is still evolving and there has been no standardization of patient selection, neuro-interventional techniques, or adjunctive therapy. IA fibrinolytics are rarely used as the sole IA therapy. Mechanical clot removal using devices designed for this purpose, new catheter techniques, and new adjunctive antithrombotic agents should improve the degree, speed and safety of IA recanalization. The number of patients subjected to unnecessary angiography and futile IA intervention can potentially be reduced by the emergent performance of non-invasive vascular screening and by identifying salvageable brain tissue thru new technologies such as perfusion-diffusion MRI. Lastly, IA thrombolysis can be combined not only with IV thrombolysis, but also with cytoprotective strategies to improve patient outcomes after acute ischemic stroke. There remain many challenges for IA thrombolysis which will require the design of focused clinical trials.
