Memet ASLANYAVRUSU, Gülhan SARIÇAM, Fahrettin EGE
The Injector - 2026;5(1):32-45
Acute ischemic stroke remains one of the leading causes of mortality and long-term disability worldwide. Over the past decade, major advances in intravenous thrombolytic therapy, mechanical thrombectomy, and advanced neuroimaging have revolutionized the treatment of acute ischemic stroke by expanding therapeutic options and improving patient selection. Nevertheless, treatment outcomes remain limited by mechanisms such as microvascular dysfunction, neurovascular unit injury, and neuroinflammation, which may persist despite successful recanalization. This review provides a comprehensive overview of current therapeutic strategies for acute ischemic stroke, integrating evidence from contemporary international guidelines and recent high-quality clinical trials. Current indications for intravenous thrombolytic therapy, the expanding role of tenecteplase, evolving indications for mechanical thrombectomy, and the contribution of advanced neuroimaging to patient selection are discussed. Recent evidence supporting endovascular treatment in patients with large infarct cores, as well as randomized trial evidence not supporting routine endovascular treatment for medium or distal vessel occlusions, is also reviewed. In addition, the roles of organized stroke unit care, antithrombotic therapy, blood pressure and glucose management, decompressive surgery, early rehabilitation, and secondary stroke prevention are highlighted. Finally, emerging therapeutic approaches, including neuroprotective agents, stem cell-based therapies, and artificial intelligence-assisted clinical decision support systems, are discussed as promising strategies that may further improve stroke care. Current evidence indicates that the management of acute ischemic stroke is evolving from a time-based approach toward a personalized, imaging-guided, and multidisciplinary treatment paradigm. The integration of reperfusion therapies with comprehensive supportive care and evidence-based secondary prevention strategies is expected to further improve clinical outcomes, while ongoing advances in neuroprotective, regenerative, and precision medicine approaches are expected to further expand future therapeutic opportunities.
