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For the Chapter in the Schwinghammer Handbook, please go to Chapter 13, Stroke.



  • Updated guidance regarding the use of tenecteplase for the treatment of acute ischemic stroke.



  • imageStroke can be either ischemic (87%) or hemorrhagic (13%), and the two types are treated differently.

  • imageTransient ischemic attacks (TIAs) require urgent intervention to reduce the risk of stroke, which is known to be highest in the first few days after TIA.

  • imageIn patients with an ischemic stroke and a blood pressure (BP) <220/120 mm Hg without comorbid conditions requiring acute hypertensive treatment, the acute lowering of BP in the first 48 to 72 hours after stroke onset does not improve survival or the level of dependency; “permissive hypertension” (BP up to 220/120 mm Hg) is often allowed. In patients with intracranial hemorrhage and elevated systolic blood pressure (SBP) between 150 and 220 mm Hg, the acute lowering of SBP to lower than 140 mm Hg is safe and may improve functional outcomes.

  • imageThrombectomy is strongly recommended for patients with anterior circulation arterial occlusion in the internal carotid artery (ICA) or the M1 segment of the middle cerebral artery (MCA) who are within 6 hours of symptom onset and may be considered in select patients within 6 to 24 hours of symptom onset.

  • imageIn patients with ischemic stroke and 70% to 99% stenosis of the carotid artery, carotid endarterectomy or carotid stenting should be performed.

  • imageEarly pharmacologic reperfusion (initiated less than 4.5 hours from symptom onset) with intravenous alteplase or tenecteplase has been shown to improve functional ability after ischemic stroke.

  • imageAntiplatelet therapy is the cornerstone of antithrombotic therapy for the secondary prevention of noncardioembolic ischemic stroke.

  • imageOral anticoagulation is recommended for the secondary prevention of cardioembolic stroke in moderate- to high-risk patients.

  • imageElevated blood pressure is very common in ischemic stroke patients, and treatment of hypertension in these patients is associated with a decreased risk of stroke recurrence.

  • imageStatin therapy is recommended for all ischemic stroke patients, regardless of baseline cholesterol, to reduce stroke recurrence.



Watch the video entitled “What is a stroke?” ( in Khan Academy. This 11-minute video provides an overview of stroke and is useful to enhance understanding of stroke pathophysiology.


Stroke is the leading cause of disability among adults and the fifth leading cause of death in the United States, behind cardiovascular disease, cancer, unintentional injuries, and chronic lower respiratory diseases.1 Although the incidence of stroke has been trending downward, approximately 795,000 strokes occur annually, contributing to nearly 148,000 deaths each year.2 Aggressive efforts to organize stroke care at the local and regional levels and increased utilization of evidence-based recommendations and national ...

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