Modern Medicine in Acute Ischemic Stroke: What Every Patient Needs to Know

AUDIO:

 The information in the following Q&A is based entirely on the review article “Acute Ischemic Stroke”, published in 2020 in The New England Journal of Medicine—one of the most authoritative medical journals in the world. The lead author of the publication is Dr. William J. Powers, Professor of Neurology at the University of North Carolina School of Medicine, USA, and an internationally recognized expert in cerebrovascular disease. The article provides a comprehensive scientific overview of current strategies for diagnosis, therapy, and follow-up in patients with acute ischemic stroke. The information presented below is intended to support patients and their families by answering the most important practical questions that arise with this diagnosis, with the hope of being a source of clarity and reassurance during a critical time for their health.

“The benefits of treatment in acute ischemic stroke are directly dependent on time— the earlier therapy begins, the greater the chance for full recovery.”

Expert Perspectives

Acute ischemic stroke is one of the most serious and life-threatening medical conditions, requiring immediate and competent intervention. Advances in diagnosis and therapy over the past few decades have significantly improved outcomes for patients, but proper treatment selection and speed of response remain critical. That is why it is especially important for patients and their families to have access to accurate, expert, and up-to-date information in order to make informed decisions about treatment. Below are five key expert opinions and quotes that reflect the current scientific and clinical advances in treating acute ischemic stroke. Each is accompanied by an explanatory heading and question to help guide patients and their loved ones.

1. How quickly should treatment start, and why is time so important?

“Treatment of patients with acute ischemic stroke is guided by time from symptom onset, severity of neurologic deficit, and findings on neuroimaging... The benefit of alteplase and mechanical thrombectomy depends on time, so evaluation and treatment should be performed quickly.”

Explanation: Every minute of delay in starting treatment reduces the chance of full recovery. This is why hospitals have “stroke teams” that act according to predefined protocols. Immediate evaluation and intervention can save brain cells and reduce the risk of long-term disability.

2. What are the main therapeutic approaches in the first hours after a stroke?

“Intravenous thrombolysis with alteplase (recombinant tissue plasminogen activator) improves outcomes in selected patients with acute ischemic stroke when administered within 4.5 hours of onset. Later treatment may benefit carefully selected patients, with a treatment window extended up to 9 hours from onset. Intra-arterial mechanical thrombectomy for occlusion of large intracranial arteries improves outcomes when performed up to 24 hours from onset.”

Explanation: The first-line treatment for eligible patients is intravenous thrombolysis—an injection that dissolves clots. In cases of large vessel occlusion, mechanical thrombectomy is used—a minimally invasive procedure that removes the clot via a catheter. The availability of these options depends on the time elapsed since symptom onset and the results of imaging studies.

3. What are the risks and benefits of using alteplase?

“In a meta-analysis of nine randomized controlled trials, 32.9% of patients in the alteplase group, compared with 23.1% in the control group, had a favorable outcome at 3 months... Major intracerebral hemorrhage occurred in 6.8% of patients in the alteplase group and 1.3% in the control group. Overall outcomes reflect both the harmful effect of hemorrhage and the beneficial effect on recovery.”

Explanation: Alteplase significantly increases the likelihood of full or near-full recovery if administered promptly but carries a risk of brain hemorrhage. The decision to use it is made after a careful evaluation of the benefits and risks.

4. When and for whom is mechanical thrombectomy used?

“Mechanical thrombectomy... performed within 6 hours of onset is first-line therapy for selected patients according to multiple randomized controlled trials showing benefit. Pooled data show that the rate of patients with good outcome (modified Rankin Scale 0–2 at 90 days) is higher among those undergoing thrombectomy—46% versus 26.5%.”

Explanation: This approach is recommended for large vessel occlusions, especially when thrombolysis is contraindicated or ineffective. For some patient groups, the procedure is effective even up to 24 hours after symptom onset, but selection is made using additional neuroimaging diagnostics.

5. What are the current recommendations for general medical care and prevention of complications?

“Patients should be admitted to a specialized stroke unit. Cardiac monitoring should be performed for at least the first 24 hours. Supplemental oxygen should be provided if oxygen saturation falls below 94%. Sources of fever should be identified and treated. Hyperglycemia should be treated... Intermittent pneumatic compression stockings are recommended for immobile patients to prevent deep vein thrombosis... Patients with large infarcts should be monitored for cerebral edema and possible neurosurgical intervention.”

Explanation: Effective medical care after stroke includes strict monitoring of vital signs, prevention of infectious and thrombotic complications, and early rehabilitation. A multidisciplinary team is crucial for long-term recovery outcomes.

Questions and Answers

1. What are the first steps if a stroke is suspected? What should I expect upon hospital admission?

Answer:

“Sudden onset of neurologic deficits localized to a specific cerebral arterial territory is the classic clinical presentation of acute ischemic stroke. Blood glucose should be routinely measured to exclude hypoglycemia. Brain imaging (usually non-contrast CT) is necessary to exclude intracerebral hemorrhage; it is preferred due to its availability, speed, and high sensitivity.”

2. How is stroke severity determined, and what does it mean for treatment?

Answer:

“The severity of neurologic deficit is measured with the National Institutes of Health Stroke Scale (NIHSS), which ranges from 0 to 42, with lower scores indicating milder deficits. Severity is categorized as disabling or non-disabling—that is, whether it interferes with essential daily activities or return to work.”

3. What tests are performed to determine whether I can receive thrombolysis or thrombectomy?

Answer:

“Certain interventions may require additional neuroimaging. Non-contrast CT is used to determine the ASPECTS score (a scale assessing ischemic changes). Diffusion-weighted MRI and CT perfusion imaging define the volume of irreversibly damaged brain tissue (‘core’) and potentially salvageable tissue (‘penumbra’), while CT or MR angiography identifies the site of occlusion.”

4. Are there other medications besides alteplase used to treat stroke, and how do they differ?

Answer:

“Tenecteplase is a modified tissue plasminogen activator with a longer half-life that can be administered as a single bolus. A meta-analysis of five randomized trials showed no significant difference between tenecteplase and standard-dose alteplase regarding the proportion of patients with a good outcome at 90 days (58.2% vs. 55.6%).”

5. If I can’t receive thrombolysis or thrombectomy, are there other medications that can help?

Answer:

“In patients with mild acute ischemic stroke who are not candidates for intravenous thrombolysis or mechanical thrombectomy, dual antiplatelet therapy with clopidogrel and aspirin, started within 24 hours and continued for 21 days, reduces the risk of recurrent stroke.”

Conclusion

The answers provided summarize the key facts and recommendations from the publication by Dr. William J. Powers and co-authors in The New England Journal of Medicine, offering accessible and evidence-based information for anyone facing a diagnosis of acute ischemic stroke. Advances in medical science, modern diagnostics, and improvements in treatment significantly increase the chances of good recovery, but awareness and timely action remain critical. We hope that these clearly explained answers will help patients and their families better understand the situation and the available paths to treatment and recovery.

Source: Powers, W. J. “Acute Ischemic Stroke.” The New England Journal of Medicine, 2020; 383:252–260. https://doi.org/10.1056/NEJMcp1917030