Update on Treatment of Acute Ischemic Stroke

Alejandro A. Rabinstein, MD, FAAN Cerebrovascular Disease p. 268-286 April 2020, Vol.26, No.2 doi: 10.1212/CON.0000000000000840
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EDITOR’S NOTE The article “Update on Treatment of Acute Ischemic Stroke” by Dr Rabinstein was first published in the February 2017 Cerebrovascular Disease issue of Continuum: Lifelong Learning in Neurology as “Treatment of Acute Ischemic Stroke” and has been updated by Dr Rabinstein for this issue at the request of the Editor-in-Chief.


This article provides an update on the state of the art of the treatment of acute ischemic stroke with particular emphasis on the indications for reperfusion therapy.


In addition to the previously established indications for intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rtPA) within 4.5 hours of stroke symptom onset and endovascular therapy with mechanical thrombectomy for patients with large artery occlusion who can be treated within 6 hours of symptom onset, recent randomized controlled trials have now established new indications for emergency reperfusion in patients with wake-up stroke or delayed presentation (up to 24 hours from last known well in the case of mechanical thrombectomy). Identification of patients who may benefit from acute reperfusion therapy within this extended time window requires screening with perfusion brain imaging or, in the case of IV thrombolysis for wake-up strokes, emergency brain MRI. Collateral status and time to reperfusion remain the primary determinants of outcome.


Timely successful reperfusion is the most effective treatment for patients with acute ischemic stroke. Recent evidence supports the expansion of the time window for reperfusion treatment in carefully selected patients.

Address correspondence to Dr Alejandro Rabinstein, Mayo Clinic, Department of Neurology, W8B, 200 First St SW, Rochester, MN 55905, [email protected].

RELATIONSHIP DISCLOSURE: Dr Rabinstein has served as an associate editor for Neurocritical Care and on the editorial board of Continuum: Lifelong Learning in Neurology. Dr Rabinstein has received royalties from Elsevier, Oxford University Press, and UpToDate, Inc.

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Dr Rabinstein discusses the unlabeled/investigational use of alteplase for the treatment of acute ischemic stroke beyond 3 hours and tenecteplase for the treatment of acute ischemic stroke.

© 2020 American Academy of Neurology.