Investigational drugs for ischemic stroke: what's in the clinical development pipeline for acute phase and prevention?

Introduction: Stroke is a leading cause of disability and mortality and its burden expected to increase. The only approved drug for acute ischemic stroke (IS) is the intravenous thrombolytic alteplase. The risk of bleeding complications is one of the reasons for the undertreatment of eligible patients. Numerous drugs are currently being developed to improve safety-efficacy. Areas covered: We reviewed literature from 1 January 2000, to 15 January 2022 for the development and testing of novel drugs with the aim of targeting treatment at prevention of ischemic stroke: PubMed, MEDLINE, Google Scholar, and ClinicalTrial.gov. Expert opinion: The pathophysiology of IS involves multiple pathways causing cerebral artery obstruction and brain tissue ischemia. Data suggest that tenecteplase is a promising fibrinolytic agent with a superior efficacy-safety profile, compared to alteplase. Current guidelines consider a short-term cycle of mannitol or hypertonic saline to be advisable in patients with space-occupying hemispheric infarction. Regarding primary and secondary prevention, research is primarily focused on identifying mechanisms to improve the safety-efficacy profile using a ‘hemostasis-sparing’ approach. Further evaluation on those agents that have shown promise for their risk/benefit profiles, would benefit greatly a neurologist’s capacity to successfully prevent and treat IS patients.