Ischemic Stroke – Practical Insights from Modern Science

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 The information presented in this article is based on the scientific review “Ischemic Stroke” by Professor Dr. Steven K. Feske, a leading neurologist and researcher at Boston Medical Center and Boston University School of Medicine. The review was published in The American Journal of Medicine in 2021 (Feske, S.K., "Ischemic Stroke", The American Journal of Medicine, 2021). This article combines the author’s extensive clinical and research experience with the latest evidence on the causes, diagnosis, treatment, and prevention of ischemic stroke. The information provided here aims to give patients practical and reliable guidance that can help them make informed decisions after a stroke or if they are at increased risk.

“Acting fast during a stroke can save brain function—and lives.”

What the Experts Say 

Ischemic stroke is one of the leading causes of death and disability worldwide. Despite significant medical advances in recent decades, timely recognition, diagnosis, and treatment remain crucial for outcomes. Patients, their families, and treating physicians are often faced with difficult decisions in the first minutes and hours after a stroke. That’s why it’s essential to rely on the expertise of leading specialists and the most up-to-date scientific recommendations. Below are five key expert insights, framed as practical questions, that can help guide patients and their loved ones through the most important aspects of stroke prevention, diagnosis, and treatment.

1. How much time do we have to react to a stroke, and why is quick intervention so critical?

“The progression of stroke over hours provides a short time for early intervention... The duration of delay until the completion of infarction varying from minutes to many hours provides both an opportunity for urgent therapy to restore blood flow and also an imperative to act rapidly, before the window of opportunity to minimize the stroke volume closes.”

Interpretation: Every minute counts—timely medical intervention can save brain tissue and determine whether a patient recovers fully or suffers lasting disability. This requires immediate transport to a hospital with specialized stroke care.

2. What is an ischemic stroke, and what are its main causes?

“Embolism is the commonest mechanism of stroke. The great majority of emboli are blood clots generated from the heart (cardioembolism) due to cardiac disease. Common cardiac disorders leading to stroke include atrial fibrillation, valvular heart disease, and cardiomyopathy from myocardial infarction or hypertension… Large vessel disease is another common underlying cause of stroke… Small vessel disease typically causes small deep strokes.”

Interpretation: Most strokes are caused by blood clots that block blood vessels in the brain, often originating from the heart (e.g., in atrial fibrillation). Other causes include atherosclerosis (blockage of large arteries) and damage to small vessels, especially in people with chronic high blood pressure or diabetes.

3. What are the main diagnostic methods, and why is neuroimaging so important?

“A patient presenting with acute onset of a focal neurologic deficit should undergo a rapid, focused history and examination... The patient should then proceed immediately to urgent brain imaging. Noncontrast head computed tomography (CT) is, in most institutions, the first study of choice... To plan for possible urgent thrombectomy, many centers typically add vascular imaging with CT angiography (CTA) to the initial CT study.”

Interpretation: Initial tests include a non-invasive CT scan to rule out bleeding and guide the choice of therapy. If a large vessel blockage is suspected, CT angiography is done to assess the potential for endovascular intervention. Fast and accurate imaging is essential for successful outcomes.

4. What are the established therapies for acute ischemic stroke, and which patients benefit most?

“All eligible patients should be offered IV thrombolysis and/or thrombectomy to optimize outcomes... All patients presenting within 6 hours of onset with significant functional deficits, with a large vessel occlusion, and without a large established stroke on CT or MRI and without contra-indications, and additionally selected patients up to 24 hours, should be considered for endovascular thrombectomy. Selection for late-window (> 6 hr) intervention is defined by imaging to confirm the likelihood of recoverable tissue at risk and a small established core infarct.”

Interpretation: Intravenous thrombolysis and mechanical thrombectomy have revolutionized stroke treatment, especially for patients with large brain vessel blockages. Those who arrive early (within 6 hours) benefit most, but new research has extended the treatment window up to 24 hours in some cases, if imaging shows salvageable brain tissue.

5. How can future strokes be prevented, and what role do medications and lifestyle changes play?

“Except when displaced by anticoagulants or when contra-indicated due to bleeding risks, antiplatelet agents should be given for secondary stroke prevention in almost all patients after TIA or ischemic stroke... The major decline in the incidence of stroke in recent decades correlates with major improvements in the management of vascular risk factors, including smoking cessation and control of hypertension, hypercholesterolemia, and diabetes mellitus. Therefore, it is important to address all of these conditions for both primary and secondary stroke prevention.”

Interpretation: After a stroke, ongoing treatment with antiplatelet or anticoagulant medications (such as aspirin, clopidogrel, warfarin, or newer oral anticoagulants) is essential, combined with strict control of risk factors—blood pressure, cholesterol, blood sugar, weight, and smoking. Lifestyle changes and regular medical follow-up are key to lowering the risk of another stroke.

Q&A Section

1. What are my personal stroke risk factors, and how do they influence the chances of having another stroke?

Answer: Age is the most significant demographic factor for stroke—risk increases as we get older. Women and African Americans are also at higher risk. Managing chronic conditions like high blood pressure, diabetes, high cholesterol, and avoiding smoking greatly reduces this risk. Research shows that the decline in stroke rates in recent years is largely due to better control of these conditions and preventive treatment of heart rhythm disorders, such as atrial fibrillation.

2. What tests will I undergo if I arrive at the emergency room with a suspected stroke, and why are they necessary?

Answer: The first step is an emergency CT scan of the brain to quickly determine if there is bleeding (which would rule out thrombolysis) or signs of an infarction. If mechanical treatment (thrombectomy) is considered, CT angiography is often performed. MRI may be used in unclear cases or when CT doesn’t provide enough information. Perfusion imaging (CT or MRI) helps identify brain areas that are still “salvageable.”

3. What medications will I need to take after a stroke, and why?

Answer: Most stroke patients take antiplatelet agents (like aspirin, clopidogrel, or a combination with dipyridamole), which reduce the risk of recurrence by about 20% annually. In some conditions (like atrial fibrillation, artificial heart valves, or hypercoagulability), anticoagulants such as warfarin or newer oral agents (apixaban, rivaroxaban, edoxaban, dabigatran) are needed. These are equally effective and more convenient for long-term use.

4. When and under what circumstances are surgical or specialized procedures recommended?

Answer: Surgery for stroke prevention (like carotid endarterectomy) is recommended for patients with symptomatic narrowing of the carotid artery ≥50%, if performed by an experienced surgeon. Stent placement is an alternative for select patients. For those with a patent foramen ovale (PFO) and an embolic stroke of unknown cause, consultation with a neurologist and cardiologist is recommended to consider closing the PFO. In rare vascular conditions or high-risk narrowing, decisions are made by a multidisciplinary team with experience in stroke care.

5. Does lifestyle change after a stroke really matter?

Answer: Yes! According to the article, the major decline in stroke rates in recent decades is mainly due to better control of blood pressure, cholesterol, diabetes, and quitting smoking. Additional recommendations include intensive statin therapy for patients with atherosclerotic risk, weight loss if overweight, a balanced diet, and regular physical activity. Screening and treating obstructive sleep apnea, if present, is also recommended.

Conclusion 

Ischemic stroke is a challenge for both patients and healthcare professionals, but thanks to scientific progress and good communication, survival and quality of life after stroke have improved significantly. The questions and answers presented here are based directly on the publication by Prof. Dr. Steven K. Feske and are intended to help every patient understand the most important aspects of modern stroke diagnosis, treatment, and prevention. This approach, grounded in up-to-date scientific evidence and proven clinical practice, is the most reliable path to better health and informed decision-making.

Source: Feske, S.K., "Ischemic Stroke", The American Journal of Medicine, 2021. Boston Medical Center, Boston University School of Medicine.