Current Approaches to Stroke Management in Emergency Medicine

Year 2025, Volume: 1 Issue: 1, 1 - 10, 30.09.2025

Semih Eriten

Abstract

Introduction: Stroke remains one of the leading causes of mortality and morbidity globally. Recent advances in acute ischemic stroke treatment have revolutionized emergency management approaches.
Materials and Methods: A comprehensive literature search was conducted across major databases for studies published between January 2019 and December 2024. The review included randomized controlled trials, systematic reviews, and international guidelines.
Results: Artificial intelligence-supported imaging systems achieved 92% sensitivity and 89% specificity in large vessel occlusion detection. Current European Stroke Organization guidelines support intravenous thrombolysis within 4.5 hours, while mechanical thrombectomy benefits patients up to 24 hours. Tenecteplase shows equivalent efficacy to alteplase with improved application ease.
Conclusion: Modern stroke management requires multidisciplinary, time-sensitive approaches integrating advanced imaging, evidence-based reperfusion therapies, and organized care systems. Future developments focus on AI applications, personalized strategies, and regenerative therapies.

Keywords

Acute ischemic stroke , emergency management , thrombolysis , mechanical thrombectomy , artificial intelligence , stroke systems of care , quality metrics

References

• Abilleira, S., Pérez de la Ossa, N., Jiménez, X., et al. (2019). Transfer to the local stroke center versus direct transfer to endovascular center of acute stroke patients with suspected large vessel occlusion in the Catalan territory (RACECAT). International Journal of Stroke, 14(7), 734–744. https://doi.org/10.1177/1747493019852176
• Alshehri, A., Ince, J., Panerai, R. B., Divall, P., Robinson, T. G., et al. (2024). Physiological variability during prehospital stroke care: Which monitoring and interventions are used? Healthcare, 12(8), 835. https://doi.org/10.3390/healthcare12080835
• Alzayer, R., Barakat, M., Jirjees, F., Aljamal, M. S., & Alsairafi, Z. (2023). Knowledge and awareness of stroke and associated factors in the Saudi general population: A cross-sectional study. Frontiers in Neurology, 14, 1225980. https://doi.org/10.3389/fneur.2023.1225980
• Anadani, M., Almallouhi, E., Wahlquist, A. E., Debenham, E., & Holmstedt, C. A. (2019). The accuracy of large vessel occlusion recognition scales in telestroke setting. Telemedicine and e-Health, 25(11), 1071–1076. https://doi.org/10.1089/tmj.2018.0232
• Appleton, J. P., Woodhouse, L. J., Adami, A., et al. (2020). Imaging markers of small vessel disease and brain frailty, and outcomes in acute stroke. Neurology, 94(5), e439–e452. https://doi.org/10.1212/WNL.0000000000008881
• Bae, J. W., & Hyun, D. K. (2024). Endovascular thrombectomy for acute ischemic stroke: Current concept in management. Journal of Korean Neurosurgical Society, 67(4), 397–410. https://doi.org/10.3340/jkns.2023.0181
• Banfield, W. H., Elghawy, O., Dewanjee, A., & Brady, W. J. (2022). Impact of COVID-19 on emergency department management of stroke and STEMI. The American Journal of Emergency Medicine, 57, 91–97. https://doi.org/10.1016/j.ajem.2022.04.033
• Berge, E., Whiteley, W., Audebert, H., De Marchis, G. M., Fonseca, A. C., Padiglioni, C., et al. (2021). European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. European Stroke Journal, 6(1), I–LXII. https://doi.org/10.1177/2396987321989865
• Bersano, A., Kraemer, M., Touzé, E., Weber, R., Alamowitch, S., et al. (2020). Stroke care during the COVID-19 pandemic: Experience from three large European countries. European Journal of Neurology, 27(9), 1794–1800. https://doi.org/10.1111/ene.14375
• Broderick, J. P., Silva, G. S., Selim, M., Foster, L. D., Manos, P., Spilker, J., et al. (2023). Enhancing enrollment in acute stroke trials: Current state and consensus recommendations. Stroke, 54(10), 2698–2707. https://doi.org/10.1161/STROKEAHA.123.044149
• Bukhari, S., Yaghi, S., & Bashir, Z. (2023). Stroke in young adults. Journal of Clinical Medicine, 12(15), 4999. https://doi.org/10.3390/jcm12154999
• Campbell, B. C. V., Mitchell, P. J., Churilov, L., Yassi, N., Kleinig, T. J., et al. (2018). Tenecteplase versus alteplase before thrombectomy for ischemic stroke. New England Journal of Medicine, 378(17), 1573–1582. https://doi.org/10.1056/NEJMoa1716405
• Cha, Z., Qiao, Y., Lu, Q., Ding, Y., Chen, J., Wu, Q., et al. (2024). Research progress and challenges of stem cell therapy for ischemic stroke. Frontiers in Cell and Developmental Biology, 12, 1410732. https://doi.org/10.3389/fcell.2024.1410732
• Czap, A. L., Bahr-Hosseini, M., Singh, N., Kotta, M., Chen, M., et al. (2022). Machine learning automated detection of large vessel occlusion from mobile stroke unit computed tomography angiography. Stroke, 53(5), 1651–1656. https://doi.org/10.1161/STROKEAHA.121.036091
• Dagonnier, M., Donnan, G. A., Davis, S. M., Dewey, H. M., & Howells, D. W. (2021). Acute stroke biomarkers: Are we there yet? Frontiers in Neurology, 12, 619721. https://doi.org/10.3389/fneur.2021.619721
• Elawady, S. S., Saway, B. F., Matsukawa, H., Tawk, R. G., & Hasan, D. (2024). Thrombectomy in stroke patients with low Alberta Stroke Program Early Computed Tomography Score. Journal of Stroke, 26(1), 95–103. https://doi.org/10.5853/jos.2023.02292
• Feigin, V. L., Brainin, M., Norrving, B., Martins, S., Sacco, R. L., Hacke, W., et al. (2022). World Stroke Organization (WSO): Global stroke fact sheet 2022. International Journal of Stroke, 17(1), 18–29. https://doi.org/10.1177/17474930211065917
• Ferro, J. M., Caeiro, L., & Santos, C. (2023). Anxiety after stroke: A systematic review and meta-analysis. Journal of Stroke and Cerebrovascular Diseases, 32(12), 107275. https://doi.org/10.1016/j.jstrokecerebrovasdis.2023.107275
• Gao, Y., Chen, W., Pan, Y., Wang, Y., Lin, Y., et al. (2023). Dual antiplatelet treatment up to 72 hours after ischemic stroke. New England Journal of Medicine, 389(26), 2413–2424. https://doi.org/10.1056/NEJMoa2309137
• GBD 2021 Stroke Risk Factor Collaborators. (2024). Global, regional, and national burden of stroke and its risk factors, 1990–2021: A systematic analysis for the Global Burden of Disease Study 2021. The Lancet Neurology, 23(10), 973–1003. https://doi.org/10.1016/S1474-4422(24)00369-7
• Hasan, T. F., Hasan, H., & Kelley, R. E. (2021). Overview of acute ischemic stroke evaluation and management. Biomedicines, 9(10), 1486. https://doi.org/10.3390/biomedicines9101486
• Heran, M., Lindsay, P., Gubitz, G., Smith, E. E., Casaubon, L. K., Hill, M. D., et al. (2024). Canadian Stroke Best Practice Recommendations: Acute stroke management, 7th edition practice guidelines update, 2022. The Canadian Journal of Neurological Sciences, 51(1), 1–31. https://doi.org/10.1017/cjn.2022.344
• Houkin, K., Osanai, T., Uchiyama, S., Tanaka, E., Omodaka, S., et al. (2024). Allogeneic stem cell therapy for acute ischemic stroke: The phase 2/3 TREASURE randomized clinical trial. JAMA Neurology, 81(2), 154. https://doi.org/10.1001/jamaneurol.2023.5200
• Iancu, A., Buleu, F., Chita, D. S., Dragan, S., Tudor, A., et al. (2023). Early hemorrhagic transformation after reperfusion therapy in patients with acute ischemic stroke: Analysis of risk factors and predictors. Brain Sciences, 13(5), 840. https://doi.org/10.3390/brainsci13050840
• Kamal, N., Smith, E. E., Jeerakathil, T., & Hill, M. D. (2023). Door-to-needle time quality improvement in acute ischemic stroke. Stroke, 54(11), 3214–3223. https://doi.org/10.1161/STROKEAHA.122.039452
• Korompoki, E., Ntaios, G., Tountopoulou, A., Theodorou, A., Vemmos, K., Stamatelopoulos, K., et al. (2024). Quality indicators and clinical outcomes of acute stroke: Results from a prospective multicenter registry in Greece (SUN4P). Journal of Clinical Medicine, 13(3), 917. https://doi.org/10.3390/jcm13030917
• Koska, I. O., & Selver, A. (2024). Artificial intelligence in stroke imaging: A comprehensive review. Eurasian Journal of Medicine, 55(S1), 91–97. https://doi.org/10.5152/eurasianjmed.2023.23347
• Kunz, W. G., Almekhlafi, M. A., Menon, B. K., et al. (2023). Public health and cost consequences of time delays to thrombectomy for acute ischemic stroke. Neurology, 100(11), e1126–e1138. https://doi.org/10.1212/WNL.0000000000201783
• Li, X., He, Y., Wang, D., & Rezaei, M. J. (2024). Stroke rehabilitation: From diagnosis to therapy. Frontiers in Neurology, 15, 1402729. https://doi.org/10.3389/fneur.2024.1402729
• Maas, W. J., Lahr, M. M. H., Buskens, E., van der Zee, D. J., Uyttenboogaart, M., et al. (2020). Pathway design for acute stroke care in the era of endovascular thrombectomy: A critical overview of optimization efforts. Stroke, 51(11), 3452–3460. https://doi.org/10.1161/STROKEAHA.120.030392
• Mead, G. E., Sposato, L. A., Sampaio Silva, G., Brainin, M., Burton, J. K., Davis, S., et al. (2023). A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization. International Journal of Stroke, 18(5), 499–531. https://doi.org/10.1177/17474930231156753
• Meinel, T. R., Wilson, D., Gensicke, H., Allida, S., Seiffge, D. J., et al. (2023). Intravenous thrombolysis in patients with ischemic stroke and recent ingestion of direct oral anticoagulants. JAMA Neurology, 80(3), 233–242. https://doi.org/10.1001/jamaneurol.2022.4782
• Menon, B. K., Hill, M. D., Dippel, D. W. J., et al. (2023). Endovascular thrombectomy outcomes with and without intravenous thrombolysis in stroke patients. Stroke, 54(9), 2567–2576. https://doi.org/10.1161/STROKEAHA.123.042567
• Mihai, E. E., Papathanasiou, J., Panayotov, K., Andonova, S., Ilieva, E., et al. (2023). Conventional physical therapy combined with extracorporeal shock wave leads to positive effects on spasticity in stroke survivors. European Journal of Translational Myology, 33(3), 11607. https://doi.org/10.4081/ejtm.2023.11607
• Misra, S., Singh, P., Nath, M., Kumar, R., Vibha, D., et al. (2022). Blood-based protein biomarkers for the diagnosis of acute stroke: A discovery-based SWATH-MS proteomic approach. Frontiers in Neurology, 13, 989856. https://doi.org/10.3389/fneur.2022.989856
• Mohamed, G. A., Nogueira, R. G., Essibayi, M. A., Saleem, Y., Yoo, A. J., et al. (2023). Tissue clock beyond time clock: Endovascular thrombectomy for patients with large vessel occlusion stroke beyond 24 hours. Journal of Stroke, 25(2), 282–290. https://doi.org/10.5853/jos.2023.00017
• Mouridsen, K., Thurner, P., & Zaharchuk, G. (2020). Artificial intelligence applications in stroke. Stroke, 51(8), 2573–2579. https://doi.org/10.1161/STROKEAHA.119.027479
• Neuhaus, A., Fleming, S., Arnold, M., Pérez de la Ossa, N., Fischer, U., et al. (2023). Public health campaigns for stroke awareness: A systematic review. Journal of Stroke and Cerebrovascular Diseases, 32(8), 107198. https://doi.org/10.1016/j.jstrokecerebrovasdis.2023.107198
• Neuhaus, A., Holmstedt, C. A., Brown, A. T., et al. (2023). ASPECTS progression and outcome prediction in acute ischemic stroke. Stroke, 54(6), 1878–1887. https://doi.org/10.1161/STROKEAHA.122.041738
• Panos, L., Bargiotas, P., Arnold, M., Hadjigeorgiou, G., & Panos, G. (2024). Revolutionizing stroke recovery: Unveiling the promise of stem cell therapy. Drug Design, Development and Therapy, 18, 991–1006. https://doi.org/10.2147/DDDT.S460998
• Patterson, J. L., Dusenbury, W., Stanfill, A., Brewer, B. B., Alexandrov, A. V., et al. (2023). Transferring patients from a primary stroke center to higher levels of care: A qualitative study of stroke coordinators' experiences. Stroke: Vascular and Interventional Neurology, 3(3), e000678. https://doi.org/10.1161/SVIN.122.000678
• Potla, N., & Ganti, L. (2022). Tenecteplase vs. alteplase for acute ischemic stroke: A systematic review. International Journal of Emergency Medicine, 15(1), 1. https://doi.org/10.1186/s12245-021-00399-w
• Powers, W. J., et al. (2021). Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline from the American Heart Association/American Stroke Association. Stroke, 52(7), e364–e467. https://doi.org/10.1161/STR.0000000000000375
• Qureshi, A. I., Baskett, W. I., Huang, W., Myers, D., Lobanova, I., et al. (2021). Acute ischemic stroke and COVID-19: An analysis of 27,676 patients. Stroke, 52(3), 905–912. https://doi.org/10.1161/STROKEAHA.120.031786
• Richards, C. T., Oostema, J. A., Chapman, S. N., Bobrow, B. J., Smith, W. S., et al. (2023). Prehospital stroke care part 2: On-scene evaluation and management by emergency medical services practitioners. Stroke, 54(5), 1416–1425. https://doi.org/10.1161/STROKEAHA.123.039792
• Roaldsen, M. B., Lindekleiv, H., Eltoft, A., Jusufovic, M., Søyland, M. H., et al. (2021). Tenecteplase in wake-up ischemic stroke trial: Protocol for a randomized-controlled trial. International Journal of Stroke, 16(8), 990–994. https://doi.org/10.1177/1747493020984073
• Robba, C., Zanier, E. R., Lopez Soto, C., Badenes, R., Banzato, E., et al. (2024). Mastering the brain in critical conditions: An update. Intensive Care Medicine Experimental, 12(1), 1. https://doi.org/10.1186/s40635-023-00587-3
• Robbins, B. T., Howington, G. T., Swafford, K., Zummer, J., & Woolum, J. A. (2023). Advancements in the management of acute ischemic stroke: A narrative review. Journal of the American College of Emergency Physicians Open, 4(1), e12896. https://doi.org/10.1002/emp2.12896
• Saceleanu, V. M., Toader, C., Ples, H., Bleotu, C., Marinescu, A. A., Panea, C. A., et al. (2023). Integrative approaches in acute ischemic stroke: From symptom recognition to future innovations. Biomedicines, 11(10), 2617. https://doi.org/10.3390/biomedicines11102617
• Sakamoto, Y., Suzuki, K., Abe, A., Aoki, J., Kanamaru, T., et al. (2020). Reducing door-to-reperfusion time in acute stroke endovascular therapy using magnetic resonance imaging as a screening modality. Journal of NeuroInterventional Surgery, 12(11), 1080–1084. https://doi.org/10.1136/neurintsurg-2019-015625
• Schlemm, L., Braemswig, T. B., Boutitie, F., Ebinger, M., Endres, M., Fiebach, J. B., et al. (2022). Cerebral microbleeds and treatment effect of intravenous thrombolysis in acute stroke. Neurology, 98(3), e302–e314. https://doi.org/10.1212/WNL.0000000000013055
• Schwarting, J., Froelich, M. F., Kirschke, J. S., Prothmann, S., Meyer, L., et al. (2024). Endovascular thrombectomy is cost-saving in patients with acute ischemic stroke with large infarct. Frontiers in Neurology, 15, 1324074. https://doi.org/10.3389/fneur.2024.1324074
• Shen, Z., Bao, N., Tang, M., Chen, R., Xiao, L., Wu, L., et al. (2023). Tenecteplase vs. alteplase for intravenous thrombolytic therapy of acute ischemic stroke: A systematic review and meta-analysis. Neurological Therapy, 12(5), 1553–1572. https://doi.org/10.1007/s40120-023-00530-4
• Sibon, I., Mazighi, M., & Smadja, D. (2021). Decision-making process for the management of acute stroke in patients on oral anticoagulant: From guidelines to clinical routine. Frontiers in Neurology, 12, 794001. https://doi.org/10.3389/fneur.2021.794001
• Soun, J. E., Chow, D. S., Nagamine, M., Takhtawala, R. S., Filippi, C. G., & Chang, P. D. (2021). Artificial intelligence and acute stroke imaging. American Journal of Neuroradiology, 42(1), 2–11. https://doi.org/10.3174/ajnr.A6883
• Soun, J. E., Zolyan, A., McLouth, J., Powers, W. J., Lee, J. M., & Vo, K. D. (2023). Impact of an automated large vessel occlusion detection tool on clinical workflow and patient outcomes. Frontiers in Neurology, 14, 1179250. https://doi.org/10.3389/fneur.2023.1179250
• Tanaka, K., Yamagami, H., Qureshi, M. M., Yoshimoto, T., Sakai, N., & Miyachi, S. (2024). Endovascular therapy in the extended time window for large vessel occlusion in patients with pre-stroke disability. Journal of Stroke, 26(2), 269–279. https://doi.org/10.5853/jos.2023.04259
• Thomalla, G., Boutitie, F., Fiebach, J. B., Simonsen, C. Z., Pedraza, S., Ebinger, M., et al. (2022). Effect of informed consent on patient characteristics in a stroke thrombolysis trial. Neurology, 89(13), 1400-1407