How should ischemic stroke be treated?

Acute ischemic stroke—commonly referred to as a brain infarction or cerebral infarction—requires prompt, evidence-based intervention to minimize neuronal injury and maximize functional recovery. The cornerstone of treatment is rapid reperfusion: restoring blood flow to the ischemic penumbra (the region of threatened but potentially salvageable brain tissue) before irreversible infarction occurs.

In eligible patients presenting within 3 hours (and up to 4.5 hours in select cases) of symptom onset, intravenous thrombolysis with alteplase is the first-line therapy, provided there are no contraindications such as recent major surgery, active bleeding, uncontrolled hypertension, or intracranial hemorrhage on baseline neuroimaging. For patients with large-vessel occlusion—particularly in the anterior circulation—who present within 6 hours (and up to 24 hours in carefully selected individuals based on advanced imaging criteria)—mechanical thrombectomy is strongly recommended and has demonstrated superior outcomes compared to medical management alone.

Supportive care is equally critical and includes strict control of blood pressure (avoiding precipitous drops unless hypertensive encephalopathy or other specific indications exist), normoglycemia maintenance, early dysphagia screening to prevent aspiration pneumonia, deep vein thrombosis prophylaxis with intermittent pneumatic compression or low-molecular-weight heparin (when safe), and timely initiation of multidisciplinary rehabilitation—including physical, occupational, and speech-language therapy.

Secondary prevention begins immediately and centers on identifying and managing underlying etiologies: antiplatelet therapy (e.g., aspirin, clopidogrel, or dual antiplatelet therapy for high-risk transient ischemic attack or minor stroke), high-intensity statin therapy regardless of baseline LDL, anticoagulation for atrial fibrillation or other cardioembolic sources, and aggressive control of modifiable risk factors including hypertension, diabetes mellitus, smoking cessation, and lifestyle optimization.

Outcomes depend heavily on time-to-treatment, stroke severity, age, comorbidities, and access to comprehensive stroke care. Therefore, public education on stroke recognition (using tools like FAST—Face drooping, Arm weakness, Speech difficulty, Time to call emergency services) and regional systems of stroke-ready hospitals and telestroke networks are vital components of modern stroke care.