According to WHO, 15 million people suffer a stroke worldwide annually. Of those, 1/3rd do not survive, and another third is left with significant neurological deficits. The majority of these events come under the category of ischemic strokes (87%).

Acute ischemic stroke is a medical emergency characterized by the sudden blockage of blood flow to the brain, resulting in neurological deficits. Rapid and appropriate management is crucial to minimize brain damage and improve patient outcomes. 

Early recognition of stroke symptoms is key to maximising the potential for medical intervention and more favourable stroke outcomes - the ‘time is brain’ imperative.

Remember pneumonic- BE-FAST (Balance(Loss of Balance)/Eye Vision (Deminished Vision) /Face (Facial Droop) /Arm Drift / Speech (Difficulty in Speaking) / Time (Time is Brain)) to Identifying stroke symptoms faster. Healthcare professionals should be trained to recognize stroke symptoms promptly and activate the stroke team. 

The use of validated stroke scales, such as the National Institutes of Health Stroke Scale (NIHSS), helps assess stroke severity and guide treatment decisions.

Reperfusion therapy aims to restore blood flow to the ischemic brain tissue and salvage viable neurons. The two main strategies for reperfusion include intravenous thrombolysis with tissue plasminogen activator(tPA) and endovascular thrombectomy.

Intravenous Thrombolysis Administering tPA within the first few hours (4.5 hrs window) of symptom onset can improve outcomes. However, eligibility criteria and time windows for thrombolysis should be strictly followed to minimize the risk of complications.

Endovascular Thrombectomy Involves the mechanical removal of the clot using specialized devices. Endovascular thrombectomy has shown signifi-cant benefits in selected patients with large vessel occlusions. This article provides an overview of the current approaches and strategies for the management of acute ischemic stroke.

1. Extended Time Window for Stroke Management:  Traditionally, intravenous thrombolysis with tissue plasminogen activator (tPA) was restricted to a time window of 4.5 hours after symptom onset. However, recent studies, such as the ECASS-4 and EXTEND trials, have demonstrated the safety and efficacy of thrombolysis up to 9 hours and even beyond, in selected patients, using advanced imaging techniques. This extended time window has allowed a larger number of eligible patients to benefit from reperfusion therapy.

Mechanical thrombectomy, which involves the removal of clot using endovascular techniques, has revolutionized acute ischemic stroke management. Recent trials, including the MRCLEAN, ESCAPE, DAWN, and DEFUSE 3 studies, have shown the superiority of mechanical thrombectomy over medical management alone in selected patients with large vessel occlusions. Moreover, newer-generation stent retrievers and aspiration catheters have improved procedural success rates, resulting in better patient outcomes. Thrombectomy can be considered for 24 hour of onset of stroke.

2. Imaging Advances:  Apart from CT/MRI perfusion weighted imaging, advanced post processing software tools for image analysis have improved, allowing more precise quantification of salvageable tissue such as penumbra size. Emerging techniques such as arterial spin labeling (ASL) provides non-invasive measurement of cerebral blood flow aiding in the assessment of tissue viability. These imaging advances have revolutionized acute stroke management by enabling faster and more accurate diagnosis, and are crucial for selecting reperfusion therapy.

3. Neuroprotective Strategies: Neuroprotective strategies aim to minimize secondary brain injury in acute ischemic stroke. While past trials in this area have been largely disappointing, recent studies have shown promise. For instance, the administration of neuroprotective agents such as nerinetide and NA-1 has demonstrated neuro-protective effects in specific patient populations. Furthermore, ongoing research on neuroin-flammation, oxidative stress, and excitotoxicity may uncover new therapeutic targets in the future.

4. Telestroke Units:   Telestroke programs, involving the use of telemedicine, have expanded access to specialized stroke care in remote or underserved areas. Teleconsultations allow expert stroke neurologists to remotely evaluate patients, provide treatment recommendations, and guide local healthcare providers.

Recent advances in acute ischemic stroke management have transformed the landscape of stroke care, expanding treatment options and improving patient outcomes. Extended time windows for IV tpa & mechanical thrombectomy, advanced imaging techniques, evolving neuroprotective strategies, and innovative approaches like telestroke are likely revolutionize acute brain stroke management.

Dr. Anitha Kotha
MBBS,DNB,(General Medicine)& 
Senior Consultant, Neurology
Star Hospitals