Intended for healthcare professionals

Clinical Review State of the Art Review

Management of acute ischemic stroke

BMJ 2020; 368 doi: (Published 13 February 2020) Cite this as: BMJ 2020;368:l6983
  1. Michael S Phipps, assistant professor1 2,
  2. Carolyn A Cronin, associate professor1
  1. 1Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
  2. 2Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
  1. Correspondence to: M S Phipps mphipps{at}


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.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: MSP and CAC both did the literature search and prepared the initial draft of the manuscript. Both authors were substantially involved in the conception, drafting, and editing of the manuscript. Both authors have given final approval of the manuscript and are accountable for all portions of the manuscript. MSP is the guarantor.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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