The three main treatments for stroke are clot-dissolving medication, surgical clot removal, and rehabilitation therapy. Which treatments apply depends on the type of stroke: about 87% of strokes are ischemic (caused by a blood clot blocking blood flow to the brain), while the rest are hemorrhagic (caused by bleeding in the brain). Time is the deciding factor in acute treatment, and rehabilitation begins within days regardless of stroke type.
Clot-Dissolving Medication
For ischemic strokes, the first-line treatment is an intravenous drug that breaks down the blood clot blocking an artery in the brain. Two medications are currently approved: alteplase and tenecteplase. The 2026 AHA guidelines endorse either one within 4.5 hours of symptom onset. Tenecteplase is given as a single injection, while alteplase requires an initial injection followed by a one-hour infusion. That single-dose advantage matters because it simplifies care, especially when a patient needs to be transferred quickly to another hospital for additional procedures.
The 4.5-hour window is the standard cutoff, but recent research shows tenecteplase may also help selected patients between 4.5 and 24 hours after symptoms begin. These patients are chosen based on brain imaging that confirms there’s still salvageable tissue. Not everyone qualifies. Doctors use CT or MRI scans to assess how much brain tissue has already been damaged versus how much can still be saved.
Speed matters enormously. Every minute a clot blocks blood flow, roughly 1.9 million neurons die. That’s why emergency systems are increasingly using mobile stroke units, specialized ambulances equipped with CT scanners that can diagnose and begin treatment before the patient even reaches a hospital.
Surgical Clot Removal
Endovascular thrombectomy is a procedure where a doctor threads a thin catheter through a blood vessel (usually starting at the groin) up to the blocked artery in the brain and physically pulls the clot out. It’s used for large vessel occlusions, meaning a clot is stuck in one of the brain’s major arteries. Only about 10% of ischemic stroke patients have this type of blockage and present early enough to qualify within 6 hours. Another 9% of patients arriving in the 6- to 24-hour window may also be eligible based on imaging.
The results are significant. Successful clot removal increases the probability of a good functional outcome by about 20 percentage points compared to medication alone. Among patients who had successful reopening of the blocked artery, 39% achieved a good functional outcome. The procedure can be performed alongside clot-dissolving medication or on its own when medication isn’t an option.
Recent guidelines have expanded who qualifies. Patients with larger areas of brain damage than previously allowed, and those with blockages in the basilar artery (which supplies the back of the brain), are now candidates if they present within 24 hours and meet specific severity thresholds.
Hemorrhagic Stroke Treatment
When a stroke is caused by bleeding rather than a clot, the treatment goals flip: instead of dissolving something, doctors need to stop the bleeding and reduce pressure on the brain. Clot-dissolving drugs would make a hemorrhagic stroke worse, which is why brain imaging before any treatment is critical.
Blood pressure control is the immediate priority. Guidelines recommend lowering systolic blood pressure to below 140 mmHg within hours of the bleed, based on large trials involving thousands of patients. Keeping blood pressure in this range helps limit how much the bleeding expands.
If the hemorrhage was caused by a ruptured aneurysm (a weak, ballooning spot in a blood vessel), two surgical options exist. Microsurgical clipping involves opening the skull and placing a tiny metal clip at the base of the aneurysm to seal it off. Endovascular coiling is less invasive: a catheter delivers small platinum coils into the aneurysm, causing it to clot and seal from the inside. Data from the International Subarachnoid Aneurysm Trial found coiling reduced the risk of death or dependency at one year by about 7 percentage points compared to clipping. However, coiling carries a slightly higher rate of recurrent bleeding in the first year (3% versus 1.3% for clipping) and more often requires repeat procedures over the following years.
Rehabilitation After Stroke
Rehabilitation is the third core treatment, and it typically starts within 24 to 48 hours of the stroke while you’re still in the hospital. It continues for weeks, months, or longer depending on the severity of the damage. This isn’t optional or supplementary. It’s a treatment that directly determines how much function you recover.
The specific therapies depend on what the stroke affected:
- Physical therapy focuses on rebuilding strength, coordination, balance, and the ability to walk. This can include range-of-motion exercises to address muscle tightness, mobility training with walkers or ankle braces, and techniques like constraint-induced therapy, where the unaffected limb is restrained to force the affected side to work harder and rebuild neural pathways.
- Occupational therapy targets everyday tasks like dressing, eating, and bathing. It also addresses cognitive problems, including memory, problem-solving, and judgment, which are common even when physical recovery goes well.
- Speech therapy helps with speaking, understanding language, reading, and writing. It can also address swallowing difficulties, which affect many stroke survivors and carry a risk of choking or pneumonia if untreated.
Some rehabilitation programs incorporate newer approaches like functional electrical stimulation, where small electrical currents cause weakened muscles to contract and retrain movement patterns, or virtual reality systems that use video games to make repetitive exercises more engaging. The brain’s ability to rewire itself (neuroplasticity) is highest in the first weeks and months after a stroke, which is why early, intensive rehabilitation produces the best outcomes.