Acute Stroke Management: Overview and Recent Updates

Stroke is a leading cause of morbidity and mortality in the United States. Whether hemorrhagic or ischemic, stroke leads to severe long-term disability. Prior to the mid-1990s, the treatment offered to a patient who presented with an acute stroke was mainly limited to antiplatelets. The lack of adequate treatment, in particular, one without reperfusion contributed to the disability that ensued. There have been many advances in stroke care within the past two decades, especially with the acute management of ischemic stroke. Even with these advances, it is quite alarming that only a fraction of patients receives acute stroke treatment. Numerous trials were conducted to broaden treatment eligibility in hopes that more patients can be treated acutely and safely. These trials have tested both the time window for IV tPA and endovascular therapy (EVT). Acute stroke management is moving from a universal time window approach to a concept of tissue preservation. Specifically, preserving cerebral blood flow, the penumbra, and reducing the risk of a second event. This movement is being executed through the use of multimodal CT and MRI, as well as individualizing treatment to our patients. Minimizing the initial effect of stroke changes the outcome and leads to an increased likelihood of functional independence. In this review, we discuss the recent updates of acute ischemic stroke management in regards to mechanical thrombectomy as well as thrombolytics including tenecteplase.