Outcomes in acute ischemic stroke (AIS) depend critically on rapid and accurate early diagnosis in the emergency department. Traditional prehospital tools and large vessel occlusion–focused scales facilitate triage but have limited capacity to distinguish ischemic from hemorrhagic stroke, a distinction essential for acute-phase treatment decisions. Recent advances include mobile stroke units equipped with computed tomography (CT), point-of-care laboratories, and telemedicine systems, as well as the emergence of biomarkers that enable field-based diagnosis and faster initiation of therapy. In-hospital imaging strategies incorporating CT, CT perfusion, and magnetic resonance imaging (MRI)-based tissue clocks have expanded eligibility for endovascular thrombectomy to include patients with large-core infarction or unclear-onset wake-up strokes. Prolonged cardiac monitoring and high-resolution vessel wall MRI have improved the detection of embolic sources and high-risk atherosclerotic plaques. Artificial intelligence now supports rapid imaging interpretation, workflow optimization, and treatment selection. Tenecteplase, a novel thrombolytic, provides a practical alternative to alteplase with comparable safety and efficacy, while post-thrombectomy management emphasizes individualized blood pressure control. In patients with 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 vulnerable plaques and enhance vascular outcomes. Collectively, these innovations represent a shift toward integrated, time-sensitive, and precision-based AIS care spanning prehospital assessment, emergency department management, and post-reperfusion management.

Objective
To investigate differences in the effect of intravenous (IV) thrombolysis regarding the mismatch of diffusion-weighted imaging–fluid-attenuated inversion recovery (DWI-FLAIR) among acute ischemic stroke patients who visited the emergency department (ED) within 3 hours from the onset of symptoms.
Methods
Among ED patients presenting with an acute ischemic stroke between January 2011 and May 2013 at a tertiary hospital, those who underwent magnetic resonance imaging before IV thrombolytic therapy were included in this retrospective study. Patients were divided into DWI-FLAIR mismatch and match groups. National Institutes of Health Stroke Scale (NIHSS) scores obtained initially, 24 hours after thrombolytic therapy, and on discharge, and early neurologic improvement (ENI) and major neurologic improvement (MNI) were compared.
Results
During the study period, 50 of the 213 acute ischemic stroke patients who presented to the ED were included. The DWI-FLAIR mismatch group showed a statistically significantly greater reduction in NIHSS both at 24 hours after thrombolytic therapy and upon discharge than did the match group (5.5 vs. 1.2, P<0.001; 6.0 vs. 2.3, P<0.01, respectively). Moreover, ENI and MNI were significantly greater for the DWI-FLAIR mismatch group than for the match group (27/36 vs. 2/14, P<0.001; 12/36 vs. 0/14, P=0.012, respectively).
Conclusion
Among acute ischemic stroke patients who visited the ED within 3 hours from the onset of symptoms, patients who showed DWI-FLAIR mismatch showed a significantly better response to IV thrombolytic therapy than did the DWI-FLAIR match group in terms of neurologic outcome.