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Acute ischemic stroke

What's new

The United States Department of Veterans Affairs (VA) and Department of Defense (DoD) have updated stroke rehabilitation guidelines. The updated guidelines recommend mirror therapy, rhythmic auditory stimulation, and neuromuscular electrical stimulation for improving motor outcomes, botulinum toxin for focal spasticity, and mirror therapy for unilateral spatial neglect. For dysphagia management, chin tuck against resistance (CTAR) exercises and respiratory muscle strength training are suggested, while the Shaker exercise has been excluded due to the greater effectiveness of CTAR exercises and poor patient perception of the Shaker exercise. Intrathecal baclofen is no longer recommended for severe chronic lower extremity spasticity, and antidepressants are not recommended for preventing post-stroke depression. .

Background

Overview

Definition
AIS is a rapid onset of cerebral function disturbance lasting > 24 hours or leading to death that is caused by occlusion of blood vessels limiting blood supply to the brain.
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Pathophysiology
AIS is caused due to cardioembolism (AF, valvular heart disease), arteroembolism (atherosclerotic disease in the extracranial cervical carotid or vertebral artery), lacunar (microatheroma with plaque rupture and microembolism), and embolic stroke of undetermined source. Less common causes include arterial dissection, vasculitis, vasospasm, and hypercoagulable states.
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Disease course
The blockage of blood vessels limiting blood supply to a part of brain results in AIS, which causes clinical manifestations of sudden facial droop, arm weakness, slurred speech, dizziness, and visual disturbance. Disease progression may lead to cerebral infarction, paralysis, coma and death.
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Prognosis and risk of recurrence
All-cause mortality associated with AIS is 3-fold compared with the age-matched cohort.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of acute ischemic stroke are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2025), the United States Department of Defense (DoD/VA 2025), the American College of Cardiology (ACC 2024), the American Heart Association (AHA/ASA 2024,2021,2019,2018,2014), the American Heart Association (AHA/HRS/ACC/ACCP 2024), the Canadian Cardiovascular Society ...
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Screening and diagnosis

Screening for intracranial atherosclerotic disease: as per ESO 2022 guidelines, insufficient evidence to recommend routine screening for asymptomatic intracranial atherosclerotic disease in adult stroke-free individuals.
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Classification and risk stratification

Severity assessment: as per AHA/ASA 2019 guidelines, assess patients with AIS using a stroke severity rating scale, preferably the NIHSS.
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NIH Stroke Scale (NIHSS)
Calculator
When to use
Level of consciousness
Alert, keenly responsive
Arousable by minor stimulation to obey, answer, or respond
Requires repeated stimulation to attend, or is obtunded and requires strong or painful stimulation to make movements (not stereotyped)
Responds only with reflex motor or autonomic effects, or totally unresponsive, flaccid, and areflexic
Ask month and age
Answers both questions correctly
Answers one question correctly
Answers neither question correctly
1C: 'Blink eyes' and 'squeeze hands' tasks
Performs both tasks correctly
Performs one task correctly
Performs neither task correctly
Horizontal extraocular movements
Normal
Partial gaze palsy: gaze is abnormal in one or both eyes, but forced deviation or total gaze paresis is not present
Forced deviation, or total gaze paresis is not overcome by the oculocephalic maneuver
Visual fields
No visual loss
Partial hemianopia
Complete hemianopia
Bilateral hemianopia (blind including cortical blindness)
Facial palsy
Normal symmetry
Minor paralysis (flattened nasolabial fold, asymmetry on smiling)
Partial paralysis (total or near-total paralysis of lower face)
Complete paralysis of one or both sides (absence of facial movement in the upper and lower face)
Left arm motor drift
No drift: limb holds 90 (or 45) degrees for full 10 seconds
Drift: limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not hit bed or other support
Some effort against gravity: limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some effort against gravity
No effort against gravity: limb falls
No movement
Amputation/joint fusion
Right arm motor drift
No drift: limb holds 90 (or 45) degrees for full 10 seconds
Drift: limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not hit bed or other support
Some effort against gravity: limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some effort against gravity
No effort against gravity: limb falls
No movement
Amputation/joint fusion
Left leg motor drift
No drift: leg holds 30-degree position for full 5 seconds
Drift: leg falls by the end of the 5-second period but does not hit the bed
Some effort against gravity: leg falls to bed by 5 seconds but has some effort against gravity
No effort against gravity: leg falls to bed immediately
No movement
Amputation/joint fusion
Right leg motor drift
No drift: leg holds 30-degree position for full 5 seconds
Drift: leg falls by the end of the 5- second period but does not hit the bed
Some effort against gravity: leg falls to bed by 5 seconds but has some effort against gravity
No effort against gravity: leg falls to bed immediately
No movement
Amputation/joint fusion
7: Limb ataxia
Absent
Ataxia in one limb
Ataxia in two limbs
Amputation/joint fusion
Sensation
Normal
Mild-to-moderate sensory loss: patient feels pinprick is less sharp or is dull on the affected side; or there is a loss of superficial pain with pinprick, but patient is aware of being touched
Severe or total sensory loss: patient is not aware of being touched in the face, arm, and leg
Language/aphasia
Normal
Mild-to-moderate aphasia: some obvious loss of fluency or facility of comprehension, without significant limitation on ideas expressed or form of expression (reduction of speech and/or comprehension, however, makes conversation about provided materials difficult or impossible; for example, in conversation about provided materials, examiner can identify picture or naming card content from patient's response)
Severe aphasia: all communication is through fragmentary expression; great need for inference, questioning, and guessing by the listener (range of information that can be exchanged is limited; listener carries burden of communication; examiner cannot identify materials provided from patient response)
Mute, global aphasia: no usable speech or auditory comprehension
Dysarthria
Normal
Mild-to-moderate dysarthria: patient slurs at least some words and, at worst, can be understood with some difficulty
Severe dysarthria: patient's speech is so slurred as to be unintelligible in the absence of or out of proportion to any dysphasia, or is mute/anarthric
Intubated/unable to test
Extinction/inattention
No abnormality
Visual, tactile, auditory, spatial, or personal inattention, or extinction to bilateral simultaneous stimulation in one of the sensory modalities
Profound hemi-inattention or extinction to more than one modality; does not recognize own hand or orients to only one side of space
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  • Risk assessment

Diagnostic investigations

General principles: as per AHA/ASA 2021 guidelines, obtain diagnostic evaluation for gaining insights into the etiology and planning optimal strategies for preventing recurrent stroke, completed or underway within 48 hours of the onset of stroke symptoms, in patients with ischemic stroke or TIA.
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  • Brain CT/MRI (for acute evaluation)

  • Brain CT/MRI (for secondary prevention)

  • CTA/MRA (for acute evaluation)

  • CTA/MRA (for secondary prevention)

  • Carotid and vertebral artery imaging

  • Cardiac imaging

  • Laboratory tests

  • ECG

  • Cardiac monitoring

  • Chest radiography

  • Screening for thrombophilic states

  • Screening for dyslipidemia

  • Screening for diabetes mellitus

  • Screening for obstructive sleep apnea

  • Screening for central hypothyroidism

Respiratory support

Airway support: as per AHA/ASA 2019 guidelines, provide airway support and ventilatory assistance for the treatment of patients with acute stroke having decreased consciousness or having bulbar dysfunction causing compromise of the airway.
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  • Supplemental oxygen

  • Hyperbaric oxygen therapy

Medical management

Prehospital care: as per AHA/ASA 2019 guidelines, ensure the use of a stroke assessment tool by first aid providers including emergency medical services dispatch personnel.
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  • Intravenous alteplase (timing)

  • Intravenous alteplase (pre-administration evaluation)

  • Intravenous alteplase (concomitant thrombectomy)

  • Intravenous alteplase (bleeding risk)

  • Intravenous alteplase (complications)

  • Intravenous alteplase (post-administration care)

  • Intravenous tenecteplase

  • Antiplatelet therapy

  • Anticoagulant therapy

  • Management of BP (acute treatment, indications and BP targets)

  • Management of BP (acute treatment, induced hypertension)

  • Management of BP (secondary prevention)

  • Management of glucose levels

  • Management of temperature

  • Management of cerebral edema (general principles)

  • Management of cerebral edema (medical management)

  • Management of cerebral edema (surgical management, supratentorial infarction)

  • Management of cerebral edema (surgical management, cerebellar infarction)

  • Management of seizures

  • Management of dyslipidemia

  • Therapies with no evidence for benefit

  • Palliative care

Inpatient care

Thromboprophylaxis, intermittent pneumatic compression: as per AHA/ASA 2019 guidelines, offer intermittent pneumatic compression, if not contraindicated, in addition to routine care (aspirin and hydration) to reduce the risk of DVT in immobile patients with stroke.
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  • Thromboprophylaxis (anticoagulation)

  • Thromboprophylaxis (compression stockings)

  • Antibiotic prophylaxis

  • Pressure ulcer prophylaxis

  • Nutritional support

  • Indwelling bladder catheters

Nonpharmacologic interventions

Dietary modifications
As per AHA/ASA 2021 guidelines:
Consider advising to follow a Mediterranean-type diet, typically with an emphasis on monounsaturated fat, plant-based foods, and fish consumption, with either high extra virgin olive oil or nut supplementation, in preference to a low-fat diet, to reduce the risk of recurrent stroke in patients with stroke and TIA.
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Consider advising to reduce the sodium intake by at least 1 g/day sodium (2.5 g/day salt) to reduce the risk of CVD events, including stroke, in patients with stroke or TIA and hypertension.
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  • Physical activity

  • Weight loss

  • Smoking cessation

  • Alcohol consumption

  • Substance use cessation

  • Head positioning

Therapeutic procedures

Indications for thrombectomy, 0-6 hours from onset: as per AHA/ASA 2019 guidelines, perform mechanical thrombectomy with a stent retriever in patients meeting all the following criteria:
age ≥ 18 years
pre-stroke mRS score 0-1
causative occlusion of the internal carotid artery or middle cerebral artery segment 1 (M1)
NIHSS score ≥ 6
ASPECTS ≥ 6
treatment can be initiated (groin puncture) within 6 hours of symptom onset.
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  • Indications for thrombectomy (6-24 hours from onset)

  • Technical considerations for thrombectomy

  • Intracranial angioplasty/stenting

  • Carotid artery revascularization

  • Vertebral artery revascularization

  • Ischemic preconditioning

  • Intra-arterial thrombolysis

  • Laser therapy

  • Ultrasound-enhanced systemic thrombolysis

Surgical interventions

Decompressive craniectomy, supratentorial infarction
As per AHA/ASA 2019 guidelines:
Consider performing decompressive craniectomy in patients with supratentorial infarction and decreased level of consciousness attributed to brain swelling.
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Consider performing decompressive craniectomy with dural expansion in patients, either aged ≤ 60 years
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or > 60 years, deteriorating neurologically within 48 hours from brain swelling associated with unilateral middle cerebral artery infarction despite medical therapy.
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  • Decompressive craniectomy (cerebellar infarction)

  • Extracranial-intracranial bypass surgery

Specific circumstances

Female patients, lifestyle modifications
As per AHA/ASA 2014 guidelines:
Advise a healthy lifestyle consisting of the following for primary stroke prevention in patients with cardiovascular risk factors:
regular physical activity
moderate alcohol consumption (< 1 drink/day for nonpregnant females)
abstention from cigarette smoking
diet rich in fruits, vegetables, grains, nuts, and olive oil, and low in saturated fat (such as the DASH diet)
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Advise lifestyle interventions focusing on diet and exercise for primary stroke prevention in individuals at high risk for stroke.
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  • Female patients (use of oral contraceptives)

  • Female patients (menopause)

  • Female patients (use of postmenopausal hormone therapy)

  • Female patients (secondary prevention)

  • Female patients (patients with endometriosis)

  • Female patients (patients with migraine)

  • Female patients (patients with AF)

  • Female patients (patients with cerebral venous thrombosis, nonpregnant)

  • Female patients (patients with cerebral venous thrombosis, pregnant)

  • Female patients (stroke during menstruation)

  • Female patients (transgender)

  • Pregnant patients (primary prevention)

  • Pregnant patients (IV alteplase)

  • Pregnant patients (mechanical thrombectomy)

  • Pregnant patients (anticoagulation therapy)

  • Pregnant patients (prevention of preeclampsia)

  • Pregnant patients (lipid-lowering therapy)

  • Postpartum patients

  • Patients with diabetes mellitus

  • Patients with renal disease

  • Patients with obstructive sleep apnea

  • Patients with a history of recent traumatic injury

  • Patients with a history of recent surgery

  • Patients with a history of recent ischemic stroke

  • Patients with hyperdense MCA sign

  • Patients with severe hypoattenuation lesions

  • Patients with embolic stroke of undetermined source

  • Patients with hemorrhagic transformation

  • Patients with procedural stroke

  • Patients with illicit drug use (primary prevention)

  • Patients with illicit drug use (management)

  • Patients with cerebral venous sinus thrombosis

  • Patients with neurological deficits

  • Patients with disability or impairment

  • Patients with inherited thrombophilias

  • Patients with antiphospholipid syndrome

  • Patients with hyperhomocysteinemia

  • Patients with malignancy

  • Patients with sickle cell disease (primary prevention)

  • Patients with sickle cell disease (management)

  • Patients with sickle cell disease (secondary prevention)

  • Patients with autoimmune diseases

  • Patients with autoimmune vasculitis

  • Patients with infection

  • Patients with infectious vasculitis

  • Patients with hypogonadism

  • Patients with genetic stroke syndromes

  • Patients with basilar artery occlusion (intravenous thrombolysis)

  • Patients with basilar artery occlusion (endovascular treatment)

  • Patients with basilar artery occlusion (reperfusion therapy)

  • Patients with carotid artery stenosis

  • Patients with vertebral artery stenosis

  • Patients with carotid or vertebral artery dissection

  • Patients with intracranial artery dissection

  • Patients with aortic arch atherosclerosis

  • Patients with aortic arch dissection

  • Patients with intracranial aneurysms

  • Patients with intracranial neoplasms

  • Patients with Moyamoya disease

  • Patients with lacunar stroke (prevention)

  • Patients with lacunar stroke (IV alteplase)

  • Patients with lacunar stroke (antiplatelet therapy)

  • Patients with lacunar stroke (antihypertensive therapy)

  • Patients with lacunar stroke (therapies with no evidence for benefit)

  • Patients with carotid web

  • Patients with FMD

  • Patients with vertebrobasilar dolichoectasia

  • Patients with AF (evaluation)

  • Patients with AF (anticoagulation therapy)

  • Patients with AF (LAA closure)

  • Patients with patent foramen ovale (indications)

  • Patients with patent foramen ovale (pre-closure monitoring)

  • Patients with patent foramen ovale (choice of closure method)

  • Patients with patent foramen ovale (post-closure care)

  • Patients with valvular heart disease (antithrombotic therapy)

  • Patients with valvular heart disease (valvular surgery)

  • Patients with myocardial infarction (primary prevention)

  • Patients with myocardial infarction (management)

  • Patients with intracardiac thrombi

  • Patients with congenital heart disease

  • Patients with cardiomyopathy (primary prevention)

  • Patients with cardiomyopathy (management)

  • Patients with cardiac tumors

  • Patients with infective endocarditis

  • Patients with acute pericarditis

  • Patients undergoing noncardiac surgery

Preventative measures

Primary prevention, screening for cardiovascular risks: as per AHA/ASA 2024 guidelines, obtain screening for cigarette smoking, use of other forms of tobacco, use of electronic nicotine delivery systems such as electronic cigarettes and vapes, and environmental tobacco smoke exposure in all patients to inform the risk of stroke and target cessation interventions.
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  • Primary prevention (dietary modifications)

  • Primary prevention (physical activity)

  • Primary prevention (weight loss)

  • Primary prevention (smoking cessation)

  • Primary prevention (antihypertensive therapy)

  • Primary prevention (lipid-lowering therapy)

  • Primary prevention (antiplatelet therapy)

  • Secondary prevention (antiplatelet therapy)

  • Secondary prevention (health system-based interventions)

  • Secondary prevention (behavioral changes)

Follow-up and surveillance

Monitoring for arrhythmia: as per ACC 2024 guidelines, consider obtaining rhythm monitoring in patients with stroke from presumed cardioembolic origin only if there is consideration of stopping anticoagulation or there are other treatment decisions that depend on arrhythmia detection.
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  • Rehabilitation (approach and timing)

  • Rehabilitation (motor therapy)

  • Rehabilitation (evaluation for dysphagia)

  • Rehabilitation (dysphagia therapy, nutritional support)

  • Rehabilitation (dysphagia therapy, exercises)

  • Rehabilitation (dysphagia therapy, oral hygiene)

  • Rehabilitation (dysphagia therapy, pharmacotherapy)

  • Rehabilitation (dysphagia therapy, electrical stimulation)

  • Rehabilitation (dysphagia therapy, acupuncture)

  • Rehabilitation (cognitive, speech, and sensory therapy)

  • Rehabilitation (depression and anxiety)

  • Rehabilitation (noninvasive brain stimulation)

  • Rehabilitation (telehealth)

  • Rehabilitation (community care)

Quality improvement

Emergency medical services
As per AHA/ASA 2019 guidelines:
Develop regional systems of stroke care consisting of healthcare facilities providing initial emergency care, including administration of IV alteplase, and centers capable of performing endovascular stroke treatment with comprehensive periprocedural care to which rapid transport can be arranged when appropriate.
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Develop triage paradigms and protocols to ensure that patients with a known or suspected stroke are rapidly identified and assessed by use of a validated and standardized tool for stroke screening by emergency medical services leaders, in coordination with local, regional, and state agencies and in consultation with medical authorities and local experts.
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  • Stroke centers/units

  • Organization of care

  • Telemedicine

  • Outcome measures

  • Public health measures

  • Health equity