Rapid Clinical Updates: Updates in Acute Stroke Management-Slides

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This educational material, led by Drs. Lily Ackermann, Ebrahim Barkoudah, Emiliya Melkumova, and Madison Paul, provides a comprehensive overview of stroke mechanisms, etiologies, and updates in acute stroke management. Stroke is defined clinically as a neurological deficit in a vascular territory, with infarct referring to brain tissue death identifiable on imaging and a transient ischemic attack (TIA) representing a transient neurological deficit without permanent brain injury. The document emphasizes that stroke is a symptom, not a diagnosis itself, and understanding its mechanism directs appropriate investigations and therapies.<br /><br />Stroke mechanisms discussed include embolic sources (cardioembolic, paradoxical embolism via PFO, artery-to-artery embolism), hypoperfusion (due to fixed stenosis and hypotension), branch atheromatous disease, in-situ thrombosis (e.g., thrombophilia), vasospasm, inflammatory stenosis (vasculitis), compression, and small vessel disease. The etiologies are multi-factorial, ranging from cardiac factors like atrial fibrillation and valve issues to large and small vessel pathologies.<br /><br />Management highlights stress prompt reperfusion via thrombolytics and endovascular therapy to preserve ischemic penumbra and avoid secondary brain injury. Key clinical considerations include assessing stroke severity ("How mild is too mild?"), blood pressure management (“How high is too high?”), and timing of intervention (“How late is too late?”). Regarding thrombolytics, tenecteplase may be as safe and possibly more effective than alteplase, particularly in large vessel occlusions (LVO), and is easier and cheaper to administer.<br /><br />Updates note that no stroke is too mild if symptoms are disabling. For blood pressure, controlled reduction with intravenous drips is recommended if initial management fails. New endovascular technologies enable treatment of moderately distal occlusions. Large core infarcts no longer contraindicate endovascular thrombectomy, expanding treatment options. Intravenous tPA usage may be extended up to 24 hours in selected patients guided by advanced imaging.<br /><br />Secondary stroke prevention is underscored by appropriate use of anticoagulants, especially direct oral anticoagulants (DOACs) for non-valvular atrial fibrillation patients to reduce recurrence risk. Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is advised in minor non-embolic strokes within 72 hours to decrease early recurrence.<br /><br />In summary, personalized acute stroke care integrates stroke mechanism identification, rapid reperfusion strategies, blood pressure and symptom severity management, and tailored secondary prevention to optimize outcomes.
Keywords
stroke mechanisms
acute stroke management
embolic stroke
transient ischemic attack
thrombolytics
endovascular therapy
blood pressure management
tenecteplase
secondary stroke prevention
direct oral anticoagulants