The acute stroke treatment dramatically changes for a last decade. Regarding hyper acute stroke, first line is intravenous thrombolytic therapy with recombinant tissue–type plasminogen activator (IV rt–PA). Randomized controlled studies and meta–analysis shows an efficacy and safety of IV rt–PA. Although it is difference of rt–PA dosage among countries, non–inferiority of low dosage (0.6mg/kg, Japanese standard) was nearly confirmed. In hyper acute stroke with occluded artery just after IV rt–PA, endovascular therapy (EVT) is recommended. The occluded artery can be recanalized at a higher rate compared with rt–PA alone, and ischemic penumbra can be relieved with performing EVT. The benefit of EVT was, confirmed by several clinical trial and meta–analysis, to reduce disability for patients with ischemic stroke of anterior circulation irrespective of eligibility for rt–PA. In the current situation, it should be noted that it is necessary to carry out the case selection strictly.
In order to prevent a stroke recurrence, acceptable medication by using antiplatelet and anticoagulant agents should be considered. In Japanese guidelines for the management of stroke 2015, aspirin (160～300mg/day) monotherapy is recommended to reduce the risk of recurrent stroke for patients with noncardioembolic ischemic stroke in acute phase (Grade A). The combination of antiplatelet therapy, mostly aspirin and clopidogrel, is also recommended as lower evidence for those in acute phase (Grade B). Recent meta–analysis shows that combination therapy within 3 months compared to monotherapy significantly reduces the recurrent stroke without increases the risk of hemorrhage event.
For anticoagulation therapy, there is no substantial evidence about secondary prevention in acute phase of stroke occurrence. It is reasonable to initiate oral anticoagulation within 14 days after the onset of index stroke, when a patient has no risk of hemorrhagic infarction, such as large infarct, hemorrhagic transformation in initial neuroimaging, hypertension, and bleeding tendency. Multicenter–randomized study to investigate the advantage of direct oral anticoagulants for acute phase of stroke should be needed.