Stroke Care Innovations: Beyond Time is Brain

Stroke intervention has undergone a profound transformation over the past decade. The once “narrow window” of opportunity for reperfusion has expanded, driven by advances in imaging, devices, pharmacotherapy, and systems of care. Today, the guiding principle of “time is brain” has evolved beyond speed alone; it now encompasses precision, prediction, and personalization. In this issue of Practical Neurology, we explore how far stroke care has come and where it is heading next through the lens of innovation and interdisciplinary collaboration.

Acute stroke management begins before the patient ever reaches the hospital doors. In Beyond Time is Brain: Workflow Innovations from Door to Recanalization in Large Vessel Occlusion Ischemic Stroke, Drs. Ibrikji, Sirasaltik, Chen, Russman, and Hussain outline quality improvement strategies to achieve ultra-rapid revascularization. They highlight how prehospital triage using mobile stroke units, AI-assisted imaging tools, and integrated in-hospital pathways can minimize treatment delays and optimize reperfusion outcomes.

Thrombolytic therapy continues to evolve, with tenecteplase (TNK) leading a new wave of practical and efficient treatment approaches. In Tenecteplase and the Future of Thrombolytics: A Practical Update for the Evolving Stroke Era, Dr. Bijoy Menon, the lead investigator of the landmark ACT trial, and his colleagues from the University of Calgary, provide an authoritative overview of how TNK has taken over as the new thrombolytic of choice and discuss what lies ahead for the next generation of thrombolytics in stroke care.

Mechanical thrombectomy remains the most transformative advancement in modern stroke therapy for large vessel occlusion stroke. In Breaking New Ground in Stroke Care: The Evolution and Future of Mechanical Thrombectomy, Drs. Robert Regenhardt, Sunil Sheth, and their team at the University of Texas at Houston review the remarkable progress of thrombectomy over the past few years. Their article examines next-generation devices, expanding indications, AI-assisted decision support, and global efforts to make thrombectomy accessible worldwide.

Hemorrhagic stroke care is also entering a new era. In New Frontiers in Hemorrhagic Stroke: Minimally Invasive Surgery and the Role of Endoport Systems, Dr. Mark Bain and the Cleveland Clinic neurosurgery team explore the promise of minimally invasive evacuation for intracerebral hemorrhage. Drawing insights from recent trials such as ENRICH, they discuss patient selection, procedural pearls, and the growing role of endoscopic and endoport-assisted techniques in improving outcomes.

Blood pressure management remains one of the most crucial and debated elements of acute stroke care. In Blood Pressure Targets After Stroke: How Low Is Too Low?, Dr. Adnan Qureshi, the lead investigator of the landmark ATACH-2 trial, and colleagues from the University of Missouri synthesize the current evidence base for both ischemic and hemorrhagic stroke. Their article integrates key findings from landmark trials while exploring emerging concepts such as blood pressure variability and sustainability, collateral flow dynamics, and the evolving role of neuroimaging in guiding individualized therapy.

Finally, immune-mediated cerebrovascular diseases continue to challenge even the most experienced clinicians. In The Immune Stroke Spectrum: Navigating Inflammatory Cerebrovascular Disorders, experts at the intersection of cerebrovascular disease and neuroimmunology, including myself and colleagues from the Cleveland Clinic and Massachusetts General Hospital, including Drs. Nagagopal Venna and Aneesh B. Singhal, provide a structured overview of these complex disorders and highlight how innovations in diagnosis and treatment are improving outcomes and expanding the boundaries of what is possible in stroke care.

Together, these articles illustrate the extraordinary momentum of a field on the edge of reinvention, where technological innovation, biological insight, system redesign, and clinical practice are converging to redefine what is possible in stroke care. The future of stroke management is not just faster, it is smarter, more individualized, and increasingly interconnected!

My sincere thanks to all the contributors whose insight and scholarship have made this issue of Practical Neurology a remarkable and illuminating reflection of where our field stands today, and where it is heading next.