Assessment of the Influence of Active Rehabilitation on the Recovery of Motor Disorders in the Scheme of Comprehensive Treatment after Cerebral Hemispheric Ischemic Stroke

Cerebral stroke is a «global epidemic», which occupies the leading place in the structure of the causes of disability of the adult population in most countries, having great medical, social, and economic significance. Therefore, this problem is urgent worldwide, being a priority area of the research, which is constantly explored. The earliest possible start of rehabilitation measures improves functional output and reduces the risk of recurrent stroke. Activation and rehabilitation of patients with stroke should begin from the first days of the patient’s stay at the stroke department, immediately after stabilization of the basic vital functions (breath and hemodynamics). The use of international standardized scales is recommended to assess the functional status of the patient, screening, and dynamic diagnosis of motor disorders. The purpose of the study was to evaluate the impact of active rehabilitation treatment in the scheme of comprehensive therapy of patients with cerebral hemispheric ischemic stroke on the dynamics of recovery of motor disorders, and to study their correlations. Materials and methods. The study enrolled 138 patients: 30 healthy individuals (n = 30) and 108 people with cerebral hemispheric ischemic stroke (n = 108), who were divided into two groups: the first group (n = 48), whose treatment generally followed the «classical» measures with the use of medicinal therapy in accordance with the current clinical protocol of medical care for patients with ischemic stroke and the second group (n = 60), in which patients were additionally prescribed and given two courses of rehabilitation using active rehabilitation methods after the first and the third examinations. Results and discussion. The screening was performed using standardized diagnostic scales to determine: stroke severity (National Institutes of Health Stroke Scale), post-stroke functional capacity (Modified Rankin Scale), index of daily activity and self-care ability (Barthel Activities of Daily Living Index), balance impairment (Berg Balance Scale), clinical assessment of spasticity (Modified Ashworth Scale) after acute ischemic cerebrovascular accident. Verification of indicators was performed on days 3-7, day 30, day 90, day 180 after cerebral hemispheric ischemic stroke. In the course of the research, we used modern statistical methods and analyzed the structure of motor disorders before and after treatment, determined the reliability of changes in indicators that demonstrate the dynamics of functional recovery under the influence of active rehabilitation, examined the correlations of motor disorders in the study groups. Conclusion. The obtained results show that the use of active rehabilitation methods in the scheme of comprehensive treatment of patients in acute and recovery periods of cerebral hemispheric ischemic stroke significantly increases the efficiency of recovery of motor functions after the acute cerebral accident

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THE INFLUENCE OF ACTIVE REHABILITATION ON THE RECOVERY OF COGNITIVE AND PSYCHOEMOTIONAL DISORDERS AFTER ISCHEMIC STROKE

Wiadomości Lekarskie ◽

10.36740/wlek202108123 ◽

2021 ◽

Vol 74 (8) ◽

pp. 1910-1916

Author(s):

Oleksandr O. Pushko

Keyword(s):

Ischemic Stroke ◽

Cerebrovascular Disorders ◽

Control Group ◽

Comprehensive Treatment ◽

Rehabilitation Treatment ◽

Comprehensive Therapy ◽

Group 2 ◽

Active Rehabilitation ◽

The Impact ◽

Group 1

The aim: Was to evaluate the impact of active rehabilitation treatment in the scheme of comprehensive therapy of patients with cerebral hemispheric ischemic stroke on the dynamics of recovery of cognitive and psychoemotional disorders, as well as to study their correlations. Materials and methods: The study involved 138 patients: 30 apparently healthy individuals (control group, CG, n = 30) without acute cerebrovascular disorders (anamnestic and neuroimaging), of whom 53.33% were men (n = 16) and 46.67% women (n = 14), the average age of patients in the group was 57.9 ± 1.45 years; 108 people diagnosed with cerebral hemispheric ischemic stroke (n = 108), of whom 62.96% were men (n = 68) and 37.04% women (n = 40), the average age of patients in the group was 58.4 ± 0.76 years. The neurocognitive assessment was performed using the international standardized scales: MMSE, MoCa were used to assess the cognitive sphere, and BDI, STAI (STAI SA, STAI TA) were used to assess psychoemotional disorders. Results: Patients in the comprehensive treatment scheme were additionally prescribed and given two courses of rehabilitation treatment using active rehabilitation methods after the first and third examinations, recovery of cognitive and psychoemotional disorders was significantly faster and better than in group 1, where “classical” measures were applied with the predominance of medicinal therapy. Thus, the average score on the MoCa scale during examination on days 3-7 after cerebral hemispheric ischemic stroke in group 1 was 19.71 ± 0.62 points, in group 2 – 19.17 ± 0.54 points, and during evaluation after 6 months in group 2 – 24.72 ± 0.26 points against 22.19 ± 0.41 points (p <0.0001) in group 1. According to the MMSE scale during examination on days 3-7 after cerebral hemispheric ischemic stroke, the average indicator in group 1 was 22.56 ± 0.43 points, in group 2 – 22.47 ± 0.37 points, and when evaluated after 6 months in group 2 – 25.83 ± 0.23 points against 24.35 ± 0.27 points (p = 0.0001) in group 1. Conclusions: The use of methods for active rehabilitation in the treatment of patients in acute and recovery periods of cerebral hemispheric ischemic stroke significantly contributes to the acceleration and enhancement of the recuperation of cognitive and psychoemotional functions after the acute cerebral accident. The obtained results can find practical application in improving the effectiveness of therapeutic and rehabilitation programs in patients with cerebral hemispheric ischemic stroke to reduce their post-stroke deficit.

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ЗАСТОСУВАННЯ Α-ГЛІЦЕРИЛФОСФОРИЛХОЛІНУ В СХЕМІ КОМПЛЕКСНОГО ЛІКУВАННЯ ДЛЯ ФУНКЦІОНАЛЬНОГО ВІДНОВЛЕННЯ ПІСЛЯ МОЗКОВОГО ПІВКУЛЬОВОГО ІШЕМІЧНОГО ІНСУЛЬТУ

The Medical and Ecological Problems ◽

10.31718/mep.2021.25.3-4.02 ◽

2021 ◽

Vol 25 (3-4) ◽

pp. 8-13

Author(s):

О.О. Пушко ◽

Н.В. Литвиненко

Keyword(s):

Ischemic Stroke ◽

Functional Recovery ◽

Vascular Diseases ◽

Comprehensive Treatment ◽

Post Stroke ◽

Rehabilitation Programs ◽

Comprehensive Therapy ◽

Progressive Growth ◽

Active Rehabilitation ◽

Combination Of Methods

The article considers the influence of α-glycerylphosphorylcholine in the scheme of comprehensive therapy on the dynamics of functional recovery in patients with cerebral hemispheric ischemic stroke. Against the background of the progressive growth of acute cerebral infarction, the problem of timely care is relevant. Timely treatment of stroke, based on evidence-based medicine, along with early activation and rehabilitation of patients is designed to reduce mortality and subsequent disability of patients. Given that cholinergic insufficiency and structural and functional damage of neurons play an important role in the pathogenesis of post-stroke disorders, the use of medicines for their correction, in particular α-glycerylphosphorylcholine, is justified. Choline alfoscerate, a precursor of acetylcholine and phosphatidylcholine, is broken down by enzymes into choline and glycerophosphate when ingested, and the choline thus obtained is able to improve neuronal functionality in patients with neurodegenerative and vascular diseases. The study revealed a significantly better recovery of impaired motor and cognitive functions after cerebral hemispheric stroke under the influence of comprehensive therapeutic and rehabilitation measures using active rehabilitation methods in conjunction with α-glycerylphosphorylcholine. The results obtained during the study allow us to report the advantage of a combination of methods of active rehabilitation and the use of the pharmacological agent α-glycerylphosphorylcholine. The feasibility and efficacy of α-glycerylphosphorylcholine are related to its ability to reduce motor and cognitive deficits after ischemic stroke. The scheme of comprehensive treatment of patients in acute and restorative periods of cerebral hemispheric ischemic stroke with the use of α-glycerylphosphorylcholine helps to increase the effectiveness of functional recovery after an acute cerebral accident, and can be used in the use of therapeutic and rehabilitation programs for patients after cerebral hemispheric ischemic stroke to reduce the post-stroke deficit.

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Software complex for assessment and rehabilitation of motor disorders in patients with ischemic stroke

Bulletin of Siberian Medicine ◽

10.20538/1682-0363-2019-4-136-142 ◽

2020 ◽

Vol 18 (4) ◽

pp. 136-142

Author(s):

I. V. Tolmachev ◽

V. M. Alifirova ◽

S. D. Kаzakov ◽

E. S. Koroleva

Keyword(s):

Ischemic Stroke ◽

Augmented Reality ◽

Virtual Environment ◽

Training Session ◽

Upper Extremities ◽

Cerebral Stroke ◽

Motor Disorders ◽

Software Complex ◽

Specialized Software ◽

The Impact

Objective. Development of a specialized software complex that creates a controlled virtual environment as well as to capture and calculate the movement data in the process of rehabilitation.Materials and methods. To evaluate the impact of visual stimuli created using the augmented reality system on the motor function, a software was developed that visualizes data via augmented reality glasses and processes data obtained from motion capture sensors. The study was conducted at the Department of Neurology and Neurosurgery and the Department of Medical and Biological Cybernetics of Siberian State Medical University in 2018–2019. The sample included 59 patients with acute ischemic cerebral stroke in the middle cerebral artery. The course of motor rehabilitation using augmented reality technology was ten days. The duration of one training session was 60 minutes.Results. Motor neurorehabilitation of patients with paresis of the upper extremities using augmented reality makes it possible to improve motor skills. Analysis of the accuracy of movements showed a significant increase in the value of the spectral criterion with an increase in the number of trainings, which indicates a decrease in the number of unnecessary movements during the main task. A significant increase in the number of completed movements with each subsequent training was revealed. This indicates a rise in the speed of the task over the course of rehabilitation, as well as reduction of the rest period between the attempts performed during one training session.Conclusion. The developed specialized software recreates a controlled virtual environment with the ability to register the parameters of human movement. The method was used for rehabilitation of motor disorders in patients with ischemic stroke of the brain and paresis of the upper extremities. The results of the study revealed a significant increase in the accuracy of movements, and a rise in endurance, which indicates the effectiveness of the approach in motor neurorehabilitation.

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Abstract WP366: Exploring the Association Between Physician Trust and Recurrent Stroke and Transient Ischemic Attack (TIA)

Stroke ◽

10.1161/str.51.suppl_1.wp366 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Anita Venkatesan ◽

Bernadette Boden-Albala ◽

Nina Parikh ◽

Emily Goldmann

Keyword(s):

Sex Education ◽

Medication Compliance ◽

Recurrent Stroke ◽

Controlled Trial ◽

National Study ◽

Stroke Severity ◽

Positive Health ◽

Physician Trust ◽

Ischemic Attack ◽

The Impact

Purpose: More positive health behaviors, fewer symptoms, higher quality of life, and greater treatment satisfaction have been reported among those with greater physician trust. This study assessed the relationship between physician trust and recurrent stroke/TIA within 1 year of discharge among stroke survivors in Northern Manhattan. Methods: This study used data from the Stroke Warning Information and Faster Treatment (SWIFT) study, a randomized controlled trial conducted from 2005-2012 in a multiethnic cohort of 1,193 mild/moderate ischemic stroke and TIA survivors. The goal was to assess the impact of a stroke preparedness educational intervention on emergency department arrival time after subsequent stroke symptom onset. Physician trust, assessed at baseline, was measured with one item: “What percentage of the time do you trust doctors?”. For the analysis, it was dichotomized with the cutoff at 80%. Recurrent stroke/TIA was assessed at 1 month and 1 year. The association between recurrent stroke/TIA and patient trust was evaluated using multivariate logistic regression adjusted for sociodemographics and comorbidities. Results: In the analytic sample (n=1108), those who answered both exposure and outcome, the prevalence of recurrent stroke/TIA and lack of physician trust was 10.75% and 36.46%, respectively. Consistent with the literature, Hispanics compared to whites had a higher prevalence of lack of physician trust (42.71% vs. 34.11%, p<0.001). Adjusting for race/ethnicity, intervention status, age, sex, education, marital status, smoking, insurance, hypertension, diabetes, body mass index, physical activity, and depression, those who lacked trust had greater odds of recurrent stroke/TIA (OR=1.36, 95% CI:0.86-2.18) than those who had trust. When observing the association among Hispanics and Blacks, those who lacked trust had (OR=1.27, 95% CI: 0.66-2.42) and (OR=1.26, 95% CI: 0.36-4.38) respectively, greater odds of a recurrent episode than those who had trust. Conclusion: Despite insignificant findings, a national study with a greater range of stroke severity and additional measures such as medication compliance may be warranted to provide greater insight on the effects of physician trust on stroke outcomes.

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The Impact of Post-contrast Acute Kidney Injury on In-hospital Mortality After Endovascular Thrombectomy in Patients With Acute Ischemic Stroke

Frontiers in Neurology ◽

10.3389/fneur.2021.665614 ◽

2021 ◽

Vol 12 ◽

Author(s):

Mona Laible ◽

Ekkehart Jenetzky ◽

Markus Alfred Möhlenbruch ◽

Martin Bendszus ◽

Peter Arthur Ringleb ◽

...

Keyword(s):

Acute Kidney Injury ◽

Ischemic Stroke ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

Kidney Injury ◽

Stroke Severity ◽

Post Contrast ◽

Endovascular Thrombectomy ◽

Symptomatic Intracerebral Hemorrhage ◽

The Impact

Background and Purpose: Clinical outcome and mortality after endovascular thrombectomy (EVT) in patients with ischemic stroke are commonly assessed after 3 months. In patients with acute kidney injury (AKI), unfavorable results for 3-month mortality have been reported. However, data on the in-hospital mortality after EVT in this population are sparse. In the present study, we assessed whether AKI impacts in-hospital and 3-month mortality in patients undergoing EVT.Materials and Methods: From a prospectively recruiting database, consecutive acute ischemic stroke patients receiving EVT between 2010 and 2018 due to acute large vessel occlusion were included. Post-contrast AKI (PC-AKI) was defined as an increase of baseline creatinine of ≥0.5 mg/dL or >25% within 48 h after the first measurement at admission. Adjusting for potential confounders, associations between PC-AKI and mortality after stroke were tested in univariate and multivariate logistic regression models.Results: One thousand one hundred sixty-nine patients were included; 166 of them (14.2%) died during the acute hospital stay. Criteria for PC-AKI were met by 29 patients (2.5%). Presence of PC-AKI was associated with a significantly higher risk of in-hospital mortality in multivariate analysis [odds ratio (OR) = 2.87, 95% confidence interval (CI) = 1.16–7.13, p = 0.023]. Furthermore, factors associated with in-hospital mortality encompassed higher age (OR = 1.03, 95% CI = 1.01–1.04, p = 0.002), stroke severity (OR = 1.05, 95% CI = 1.03–1.08, p < 0.001), symptomatic intracerebral hemorrhage (OR = 3.20, 95% CI = 1.69–6.04, p < 0.001), posterior circulation stroke (OR = 2.85, 95% CI = 1.72–4.71, p < 0.001), and failed recanalization (OR = 2.00, 95% CI = 1.35–3.00, p = 0.001).Conclusion: PC-AKI is rare after EVT but represents an important risk factor for in-hospital mortality and for mortality within 3 months after hospital discharge. Preventing PC-AKI after EVT may represent an important and potentially lifesaving effort in future daily clinical practice.

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Protein Biomarkers in Blood Reflect the Interrelationships between Stroke Outcome, Inflammation, Coagulation, Adhesion, Senescence and Cancer

10.20944/preprints202108.0448.v2 ◽

2021 ◽

Author(s):

Georg Fuellen ◽

Jan Böhmert ◽

Larissa Henze ◽

Daniel Palmer ◽

Uwe Walter ◽

...

Keyword(s):

Ischemic Stroke ◽

Cellular Senescence ◽

Recurrent Stroke ◽

Interaction Network ◽

Stroke Severity ◽

Protein Biomarkers ◽

Term Outcome ◽

Long Term Outcome ◽

Reactive Protein ◽

Inflammatory Processes

The most important predictors for outcomes after ischemic stroke, that is, for health deterioration and death, are chronological age and stroke severity; gender, genetics and lifestyle / environmental factors also play a role. Of all these, only the latter can be influenced after the event, even though recurrent stroke may be prevented by antiaggregant/anticoagulant therapy, angioplasty of high-grade stenoses, and treatment of cardiovascular risk factors. Moreover, blood cell composition and protein biomarkers such as C-reactive protein or interleukins in serum are frequently considered as biomarkers of outcome. We surveyed protein biomarkers that were reported to be predictive for outcome after ischemic stroke, specifically considering biomarkers that predict long-term outcome (≥3 months) and that are measured over the first days following the event. We classified the protein biomarkers as immune‑inflammatory, coagulation-related, and adhesion-related biomarkers. Some of these biomarkers are closely related to cellular senescence and, in particular, to the inflammatory processes that can be triggered by senescent cells. Moreover, the processes that underlie inflammation, hypercoagulation and cellular senescence connect stroke to cancer, and biomarkers of cancer-associated thromboembolism, as well as of sarcopenia, overlap strongly with the biomarkers discussed here. Finally, we demonstrate that most of the outcome-predicting protein biomarkers form a close-meshed functional interaction network, suggesting that the outcome after stroke is partially determined by an interplay of molecular processes relating to inflammation, coagulation, cell adhesion and cellular senescence.

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Risks of Stroke Recurrence and Mortality After First and Recurrent Strokes in Denmark: A Nationwide Registry Study

Neurology ◽

10.1212/wnl.0000000000013118 ◽

2021 ◽

pp. 10.1212/WNL.0000000000013118

Author(s):

Nils Skajaa ◽

Kasper Adelborg ◽

Erzsébet Horváth-Puhó ◽

Kenneth J Rothman ◽

Victor W. Henderson ◽

...

Keyword(s):

Ischemic Stroke ◽

Intracerebral Hemorrhage ◽

Risk Score ◽

Recurrent Stroke ◽

Recurrent Event ◽

Risk Scores ◽

Stroke Recurrence ◽

Stroke Severity ◽

Risk Of Death ◽

First Time

Background and Objectives:To examine risks of stroke recurrence and mortality after first and recurrent stroke.Methods:Using Danish nationwide health registries, we included patients (age ≥18 years) with first-time ischemic stroke (N = 105,397) or intracerebral hemorrhage (N = 13,350) during 2004–2018. Accounting for the competing risk of death, absolute risks of stroke recurrence were computed separately for each stroke subtype and within strata of age groups, sex, stroke severity, body mass index, smoking, alcohol, the Essen stroke risk score, and atrial fibrillation. Mortality risks were computed after first and recurrent stroke.Results:After adjusting for competing risks, the overall 1-year and 10-year risks of recurrence were 4% and 13% following first-time ischemic stroke and 3% and 12% following first-time intracerebral hemorrhage. For ischemic stroke, the risk of recurrence increased with age, was higher for men and following mild than more severe stroke. The most marked differences were across Essen risk scores, for which recurrence risks increased with increasing scores. For intracerebral hemorrhage, risks were similar for both sexes and did not increase with Essen risk score. For ischemic stroke, the 1-year and 10-year risks of all-cause mortality were 17% and 56% after a first-time stroke and 25% and 70% after a recurrent stroke; corresponding estimates for intracerebral hemorrhage were 37% and 70% after a first-time event and 31% and 75% after a recurrent event.Conclusion:The risk of stroke recurrence was substantial following both subtypes, but risks differed markedly among patient subgroups. The risk of mortality was higher after a recurrent than first-time stroke.

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Abstract 160: DNA-Methylation and Aging. Contribution of Biological Age to Recovery After Ischemic Stroke

Stroke ◽

10.1161/str.48.suppl_1.160 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Jordi Jimenez-Conde ◽

Carolina Soriano-Tarraga ◽

Eva Giralt-Steinhauer ◽

Marina Mola ◽

Rosa Vivanco-Hidalgo ◽

...

Keyword(s):

Dna Methylation ◽

Ischemic Stroke ◽

Functional Status ◽

Biological Age ◽

Chronological Age ◽

Bivariate Analysis ◽

Stroke Severity ◽

Age Related ◽

Recovery Capacity ◽

The Impact

Background: Stroke has a great impact in functional status of patients, although there are substantial interindividual differences in recovery capacity. Apart from stroke severity, age is considered an important predictor of outcome after stroke, but aging is not only due to chronological age. There are age-related DNA-methylation changes in multiple CpG sites across the genome that can be used to estimate the biological age (b-Age), and we seek to analyze the impact of this b-Age in recovery after an ischemic stroke. Methods: We include 600 individuals with acute ischemic stroke assessed in Hospital del Mar (Barcelona). Demographic and clinical data such as chronological age (c-Age), vascular risk factors, NIHSS at admission, recanalization treatment (rtPA or endovascular treatment), previous modified Rankin scale (p-mRS) and 3 months post stroke functional status (3-mRS) were registered. Biological age (b-Age) was estimated with Hannumm algorithm, based on DNA methylation in 71 CpGs. Results: The bivariate analyses for association with 3-mRS showed a significant results of NIHSS, c-Age, b-Age, p-mRS, and current smoking (all with p<0.001). Recanalization treatment showed no significant differences in bivariate analysis. In multivariate ordinal models, b-Age kept its significance (p=0.025) nullifying c-Age (p=0.84). Initial NIHSS, p-mRS and recanalization treatment kept also significant results (p<0.001). Conclusions: Biological Age, estimated by DNA methylation, is an independent predictor of stroke prognosis, irrespective to chronological age. "Healthy aging” affects the capacity of recovering after an ischemic stroke.

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Abstract WP286: Race and Gender Differences Among Patients With First or Recurrent Ischemic Stroke

Stroke ◽

10.1161/str.47.suppl_1.wp286 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Mary G George ◽

Xin Tong

Keyword(s):

Gender Differences ◽

Ischemic Stroke ◽

Recurrent Stroke ◽

Hospital Death ◽

Stroke Severity ◽

Race And Gender ◽

Black Females ◽

White Males ◽

Black Patients ◽

And Gender

Introduction: Little information is known about the race and gender differences in stroke severity of acute ischemic stroke (AIS) among those presenting with and without a recurrent stroke (RS). Methods: The study is limited to white and black patients who were admitted with an AIS in the Paul Coverdell National Acute Stroke Program from 2012-2014. There were 157 967 admissions from 453 hospitals identified. After excluding those with missing NIHSS (33 017), the analysis focused on 124 950 patients. Results: The median age of blacks and females was greater than for whites and males, 74 vs 63 and 75 vs 68, respectively. RS accounted for 21.8% of AIS in white males, 21.2% in white females, 28.3% in black males, and 30.0% in black females. The median NIHSS was higher among females with initial stroke or RS stroke (4.0 vs 3.0 and 5.0 vs 4.0, respectively, p<0.0001) and higher among blacks with initial stroke or RS (4.0 vs 3.0 and 5.0 vs 4.0, respectively, p<0.0001). Overall in-hospital death was greater among whites and females compared to blacks and males (4.1% vs 2.9%, p<0.0001; 4.2% vs 3.5%, p<0.0001, respectively), and this pattern was consistent for initial AIS and RS. Use of tPA was greater among whites and males compared to blacks and females (11.6% vs 10.3%, p<0.0001; 11.5 vs 11.1%, p=0.02, respectively). This pattern was consistent for initial AIS and RS by race and for initial AIS by gender, but not for tPA for RS by gender. Females and blacks were less likely to have a mild stroke (NIHSS score 0-4) than males and whites for both initial and RS (p<0.0001). After adjusting for age, state, hospital, and year, the odds of having an NIHSS ≥5 was 16% lower among males, 36% greater among blacks, and 38% greater for those with a RS (data not shown). Conclusion: Race and gender differences on age, stroke severity, receipt of tPA, and in-hospital death among initial AIS patients persist for RS. Blacks, females, and those with a RS have more severe AIS.

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Management of acute ischemic stroke

BMJ ◽

10.1136/bmj.l6983 ◽

2020 ◽

pp. l6983 ◽

Cited By ~ 15

Author(s):

Michael S Phipps ◽

Carolyn A Cronin

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Treatment Time ◽

Recurrent Stroke ◽

Time Windows ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Developed Countries ◽

Future Research ◽

The Impact

ABSTRACT Stroke is the leading cause of long term disability in developed countries and one of the top causes of mortality worldwide. The past decade has seen substantial advances in the diagnostic and treatment options available to minimize the impact of acute ischemic stroke. The key first step in stroke care is early identification of patients with stroke and triage to centers capable of delivering the appropriate treatment, as fast as possible. Here, we review the data supporting pre-hospital and emergency stroke care, including use of emergency medical services protocols for identification of patients with stroke, intravenous thrombolysis in acute ischemic stroke including updates to recommended patient eligibility criteria and treatment time windows, and advanced imaging techniques with automated interpretation to identify patients with large areas of brain at risk but without large completed infarcts who are likely to benefit from endovascular thrombectomy in extended time windows from symptom onset. We also review protocols for management of patient physiologic parameters to minimize infarct volumes and recent updates in secondary prevention recommendations including short term use of dual antiplatelet therapy to prevent recurrent stroke in the high risk period immediately after stroke. Finally, we discuss emerging therapies and questions for future research.

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