A narrative review of reperfusion therapy in acute ischemic stroke: Emerging advances, current challenges, and future directions

Abstract

Significant advancements over the past decade have transformed reperfusion therapy for acute ischemic stroke. Standard treatments, including intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT), offer distinct benefits, with recent innovations expanding their efficacy and applicability. IVT, previously limited by a narrow therapeutic window, has seen enhancement with alternative agents such as tenecteplase, which may deliver comparable or superior outcomes to alteplase in selected cases. Expanding indications for EVT, particularly for large vessel occlusions and in extended time windows, have demonstrated promising results, underscoring its effectiveness beyond conventional time constraints. Recent trials further support the use of EVT for patients with large infarct cores in the anterior circulations, although mortality outcomes remain sensitive to treatment timing. In addition, mobile stroke units (MSUs) and prehospital management strategies have emerged as critical components for minimizing delays and improving clinical outcomes. Future research should focus on optimizing reperfusion therapies to individual patient profiles, investigating neuroprotective adjuncts, and expanding the global availability of MSUs to facilitate timely, accessible stroke care.

Keywords: Acute ischemic stroke; endovascular thrombectomy; intravenous thrombolysis; neuroprotective adjuncts.

Figure 1

Acute management flowchart of ischemic stroke. ^†If IVT is contraindicated, EVT should be the sole procedure performed. AIS: Acute ischemic stroke, CT: Computed tomography, MRI: Magnetic resonance imaging, ICH: Intracranial hemorrhage, IVT: Intravenous thrombolysis, EVT: Endovascular thrombectomy, RCT: Randomized controlled trial