Initial diagnosis and management of acute ischemic stroke: recent update and future direction

Acute ischemic stroke (AIS) outcomes depend critically on rapid, accurate early diagnosis in the emergency department. Traditional prehospital tools and large vessel occlusion focused scales aid triage, but have limited ability to distinguish ischemic from hemorrhagic stroke, a distinction essential for treatment decision in acute phase. Recent advances include mobile stroke units equipped with computed tomography (CT), point-of-care labs, and telemedicine, as well as biomarkers, enabling field-based diagnosis and faster therapy initiation. In-hospital imaging strategies using CT, CT perfusion, and magnetic resonance imaging (MRI)-based tissue clocks have expanded eligibility for endovascular thrombectomy to large core and unclear onset wake-up strokes. Prolonged cardiac monitoring and highresolution vessel wall MRI enhance identification of embolic sources and high-risk atherosclerotic plaques. Artificial intelligence now supports rapid imaging interpretation, workflow optimization, and treatment selection. Tenecteplase, a novel thrombolytic, offers a practical alternative to alteplase with similar safety and efficacy, while post-thrombectomy care emphasizes individualized blood pressure management. In minor stroke or high-risk transient ischemic attack, short-term dual antiplatelet therapy reduces early recurrence, and early initiation of lipid lowering agents after AIS may stabilize unstable plaques and improve vascular outcomes. Together, these innovations mark a shift toward integrated, time-sensitive, and precision-based AIS care from prehospital assessment, emergency department care and post-reperfusion management.