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Reperfusion may be accomplished through administration of intravenous thrombolytic agents, intra-arterial thrombolysis, mechanical thromboembolectomy, ultrasound-enhanced thrombolysis and various combinations of these approaches.

Alternative or adjunct approaches include enhanced oxygen delivery, hemodilution and systemic central hemodynamic augmentation therapy [7].

Risks associated with reperfusion therapies, apart from failure to reperfuse, include intracerebral hemorrhage (ICH), ischemia–reperfusion injury and catheterization complications.

A large-scale randomized trial indicated that intravenous recombinant tissue plasminogen activator (alteplase) administered within 3 hours of ischemic stroke onset was associated with significantly improved functional outcomes when compared with placebo, but with an increased risk of ICH [8].

More recent data indicated that intravenous alteplase was beneficial when given within 4.5 hours of onset in nondiabetic patients 4.5 hours or those for whom systemic intravenous thrombolysis is contraindicated [11,14].

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Secondary biochemical changes contribute to subsequent tissue damage with associated neuronal cell death.The time course over which these effects occur may be longer than assumed previously, potentially providing a wider time window for interventions.Neuroprotective agents that can limit secondary tissue loss and/or improve behavioral outcomes have been identified in multiple animal models of acute brain injury.However, published supportive evidence is lacking and randomized trials comparing early versus delayed surgery would probably encounter ethical challenges [18].Nevertheless, in the case of epidural hematoma management, shortening the time from trauma to surgery was associated with improved outcomes in a prospective cohort study [19].

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