In-Hospital Protocal for Acute Ischemic Stroke: Evidence Regarding Neuroprotection, Mechanical Thrombectomy, and Rehabilitation Delivered by Physicians, Physiotherapists, and Nurses

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1. Introduction

Stroke remains one of the leading causes of mortality and disability worldwide, representing a major challenge for healthcare systems due to the high socioeconomic and functional impact of its sequelae. Ischemic stroke accounts for approximately 85% of cases and results from the interruption of cerebral blood flow, leading to the formation of an infarct core surrounded by a potentially salvageable region known as the ischemic penumbra. The preservation of this viable tissue constitutes the primary objective of current therapeutic strategies, as it is directly related to the functional recovery of patients (CAMPBELL; KHATRI, 2020; POWERS et al., 2019) [12, 54]. In recent decades, the treatment of acute ischemic stroke (AIS) has undergone significant transformations with the consolidation of reperfusion therapies. Intravenous thrombolysis with alteplase remains the first-line treatment for eligible patients within the recommended therapeutic window, while mechanical thrombectomy has been established as the standard of care for individuals with intracranial large vessel occlusion (LVO) (POWERS et al., 2019; BERGE et al., 2021) [54, 5]. Several studies have demonstrated that early reperfusion is associated with reduced disability and increased rates of functional independence after stroke (EMBERSON et al., 2014; SAVER et al., 2015) [21, 61].

The efficacy of mechanical thrombectomy was proven by major randomized clinical trials that demonstrated its superiority over medical management alone. Trials such as MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, and REVASCAT showed consistent benefits in neurological recovery and a reduction in functional dependence among patients undergoing endovascular reperfusion (BERKHEMER et al., 2015; CAMPBELL et al., 2015; GOYAL et al., 2015; SAVER et al., 2015; JOVIN et al., 2015) [6, 15, 24, 61, 30]. Subsequently, the DAWN and DEFUSE-3 trials extended the therapeutic window for cases selected by advanced neuroimaging methods, reinforcing the importance of individualized assessment and the organization of in-hospital stroke protocols (NOGUEIRA et al., 2018; ALBERS et al., 2018) [50, 1].

Despite the advances provided by reperfusion strategies, a significant proportion of patients remain with severe neurological deficits, even after successful recanalization of the occluded vessel. This phenomenon suggests that the restoration of blood flow alone is not always sufficient to prevent the progression of neuronal injury, especially in situations of delayed reperfusion, cerebral edema, and ischemia-reperfusion injury (CHAMORRO; DIRNAGL; URRA; PLANAS, 2016; SAVITZ et al., 2017) [17, 59]. In this context, neuroprotective strategies have attracted growing interest within the scientific community, as they seek to preserve cerebral cellular integrity before, during, and after reperfusion. Such approaches include strict blood pressure control, maintenance of normoglycemia, prevention of hyperthermia, optimization of tissue oxygenation, inflammatory modulation, and the investigation of pharmacological agents capable of reducing secondary neuronal damage (POWERS et al., 2019; DAMMAVALAM; AGHAEBRAHIM; RAI, 2024) [54, 19]. Although many neuroprotective agents have shown promising results in experimental models, the translation of these benefits into clinical practice still represents a significant challenge (NEUHAUS et al., 2017; DIRNAGL; ENDRES, 2014) [48, 20]. The era of mechanical thrombectomy has brought new perspectives to cerebral neuroprotection, given that achieving rapid reperfusion allows for the enhanced effectiveness of adjunctive therapies aimed at preserving the ischemic penumbra. Recent studies have evaluated pharmacological and non-pharmacological strategies associated with reperfusion, including neuroprotective agents, optimized hemodynamic management, and specific neurocritical care protocols (HILL et al., 2020; WANG et al., 2026) [28, 68]. These advances reinforce the need to integrate neuroprotection into established in-hospital protocols for the treatment of acute stroke.

Concurrently, the concept of the in-hospital stroke protocol has evolved beyond the simple execution of thrombolysis or thrombectomy, incorporating a continuous and multidisciplinary approach from patient admission to the rehabilitation phase. The implementation of specialized Stroke Units has demonstrated a reduction in mortality, a decrease in in-hospital complications, and a significant improvement in functional outcomes, highlighting the importance of care organization and the integrated performance of healthcare teams (STROKE UNIT TRIALISTS’ COLLABORATION, 2013; POWERS et al., 2019) [62, 54].

In this scenario, multidisciplinary practice assumes a fundamental role. Neurologists, intensivists, interventional radiologists, nurses, physical therapists, occupational therapists, speech-language pathologists, and other professionals contribute in a complementary manner to the comprehensive care of patients affected by acute ischemic stroke. The integration of rapid diagnosis, effective reperfusion, clinical neuroprotection, and early rehabilitation is directly associated with improved neurological and functional recovery (WINSTEIN et al., 2016; MINELLI et al., 2022) [70, 42].

Physical therapy holds a special prominence within this multidisciplinary approach, operating from the acute phase through respiratory management, prevention of immobility-associated complications, early mobilization, and the stimulation of neuroplasticity. Evidence shows that physical therapy interventions initiated early can contribute to motor recovery, reduced length of hospital stay, and improved functional independence in stroke survivors (LANGHORNE; BERNHARDT; KWAKKEL, 2011; POLLOCK et al., 2014; VEERBEEK et al., 2014) [32, 52, 67].

Time remains one of the main prognostic determinants in acute ischemic stroke. The concept that “time is brain” remains widely validated, demonstrating that delays in symptom recognition, neuroimaging acquisition, or the initiation of reperfusion therapies result in progressive neuronal loss and worse functional prognosis (SAVER, 2006; MERETOJA et al., 2014; RIBO et al., 2016) [60, 41, 56]. Therefore, the efficiency of in-hospital protocols and the integration across different stages of care constitute essential factors for optimizing clinical outcomes. Given the growing expansion of evidence related to mechanical thrombectomy, cerebral neuroprotection, and multidisciplinary rehabilitation, it is essential to synthesize the knowledge available in the scientific literature. Thus, this systematic review aims to analyze current evidence on neuroprotective strategies applied to acute ischemic stroke, emphasizing their integration with mechanical thrombectomy and their relevance to in- hospital care and multidisciplinary recovery protocols.

2. Objectives

2.1. General Objective

To analyze the available scientific evidence regarding neuroprotective strategies employed in the management of acute ischemic stroke, emphasizing their association with mechanical thrombectomy and their applicability to in-hospital care and multidisciplinary rehabilitation protocols.

2.2. Specific Objectives

• To identify the main neuroprotective strategies utilized during the in-hospital care of patients with acute ischemic stroke undergoing mechanical thrombectomy; • To evaluate the effects of neuroprotective interventions on patients' clinical, neurological, and functional outcomes; • To analyze the influence of early reperfusion and mechanical thrombectomy on the preservation of the ischemic penumbra and on neurological recovery; • To investigate the contribution of clinical, hemodynamic, and metabolic support measures as neuroprotective components of stroke protocols; • To describe the multidisciplinary approach, with an emphasis on medical and physical therapy involvement, during the acute and rehabilitation phases of ischemic stroke; • To synthesize current evidence to support the implementation and improvement of evidence-based in-hospital stroke protocols.

3. Methods

3.1. Study Design

This systematic literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines, aiming to identify, select, critically appraise, and synthesize the scientific evidence related to neuroprotective strategies associated with mechanical thrombectomy in acute ischemic stroke and their integration into in-hospital care and multidisciplinary rehabilitation protocols.

3.2. Search Strategy

The literature search was performed in the PubMed/MEDLINE, Scopus, Web of Science, Embase, Cochrane Library, SciELO, and Virtual Health Library (VHL) databases.

Controlled descriptors from the Medical Subject Headings (MeSH) and Health Sciences Descriptors (DeCS) were used, combined with the Boolean operators AND and OR. The search strategy was constructed using the following terms: o ("Acute Ischemic Stroke" OR "Ischemic Stroke") AND o ("Mechanical Thrombectomy" OR "Endovascular Treatment")

AND o ("Neuroprotection" OR "Neuroprotective Strategies") AND o ("Stroke Protocol" OR "Stroke Unit" OR "Hospital Protocol")

AND o ("Rehabilitation" OR "Physical Therapy" OR "Multidisciplinary Care")

The search strategy was adapted to the specific syntax of each database.

3.3. Inclusion Criteria

The following were included: • Randomized controlled trials; • Prospective and retrospective observational studies; • Systematic reviews and meta-analyses; • National and international guidelines; • Studies involving adult patients diagnosed with acute ischemic stroke; • Research addressing mechanical thrombectomy, cerebral neuroprotection, in-hospital stroke protocols, or multidisciplinary rehabilitation; • Articles published in English, Portuguese, or Spanish.

3.4. Exclusion Criteria

The following types of records were excluded:: • Case reports; • Case series with small sample sizes; • Conference abstracts without full text available; • Letters to the editor; • Experimental studies conducted exclusively in animals; • Duplicate records across databases; • Articles lacking direct relevance to neuroprotection, mechanical thrombectomy, or in-hospital care for ischemic stroke.

3.5. Study Selection

The study selection process was conducted in three stages:": 1. Identification of records from databases; 2. Screening of titles and abstracts; 3. Full-text review of potentially eligible reports.

Two independent reviewers performed all stages of the selection process. Disagreements were resolved by consensus or by consultation with a third reviewer.

3.6. Data Extraction

The following data were extracted: • Author(s) and year of publication; • Country of study; • Study design; • Sample size; • Characteristics of the study population; • Neuroprotective strategy investigated; • Type of endovascular intervention; • Neurological and functional outcomes; • In-hospital mortality; • Functional score (modified Rankin Scale – mRS); • Authors' main conclusions.

3.7. Methodological Quality Assessment

The methodological quality of the included studies was assessed using the appropriate tools for each study design: • RoB 2 (Risk of Bias 2) tool for randomized controlled trials; • Newcastle-Ottawa Scale (NOS) for observational studies; • AMSTAR 2 for systematic reviews; • AGREE II for clinical guidelines.

3.8. Data Synthesis

A narrative and descriptive synthesis of the results was conducted, grouping the studies into thematic categories related to: • Mechanical thrombectomy; • Pharmacological neuroprotection; • Non-pharmacological neuroprotection; • In-hospital care for acute stroke; • Hemodynamic and metabolic control; • Specialized stroke units; • Early multidisciplinary rehabilitation; • Physical therapy intervention and functional recovery.

The process of study identification, screening, eligibility, and inclusion was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines. Initially, systematic searches were performed in the PubMed/MEDLINE, Scopus, Web of Science, Embase, Cochrane Library, SciELO, and Virtual Health Library (VHL) databases, resulting in the identification of a substantial number of publications potentially relevant to the proposed topic. Following the removal of duplicate records and those deemed ineligible based on pre-established methodological criteria, the remaining studies underwent title and abstract screening. Subsequently, potentially eligible articles were evaluated in full to determine their adherence to the inclusion and exclusion criteria defined for this systematic review. At the end of the selection process, 75 studies met all methodological criteria and were included in the qualitative synthesis. The selected studies comprised randomized controlled trials, observational studies, systematic reviews, meta-analyses, and clinical guidelines, allowing for a comprehensive analysis of the evidence related to neuroprotective strategies, mechanical thrombectomy, in-hospital stroke protocols, and multidisciplinary rehabilitation. Full details of the study selection stages are presented in Figure 1 Fig 1: PRISMA 2020 flow diagram demonstrating the identification, screening, eligibility, and inclusion phases of studies selected for the systematic review on neuroprotection, mechanical thrombectomy, and multidisciplinary rehabilitation in acute ischemic stroke. Adapted from the PRISMA 2020 statement.

4. Results

The analysis of the 75 included studies demonstrated that the in-hospital medical protocol for acute ischemic stroke treated with mechanical thrombectomy involves an organized sequence of interventions aimed at reducing time to cerebral reperfusion, preserving the ischemic penumbra, and minimizing neurological and systemic complications (TABLE 1).

A consensus was observed among major international guidelines regarding the importance of early symptom identification, rapid vascular neuroimaging, appropriate selection for reperfusion therapies, and the adoption of neuroprotective measures throughout the hospitalization period.

The studies highlighted that the integration of intravenous thrombolysis, mechanical thrombectomy, intensive monitoring, and care in specialized stroke units is associated with improved functional outcomes and lower mortality rates. Subsequently, the involvement of the multidisciplinary team, particularly during the early rehabilitation phase, proved crucial for enhancing the neurological and functional recovery of patients.

Table 1: Main components of the in-hospital medical protocol for patients with acute ischemic stroke treated with mechanical thrombectomy, identified in the studies included in the systematic review. Phase of Care Recommended Medical Management Clinical Objective Key Evidence Early recognition Administration of screening scales (FAST, Cincinnati, NIHSS)

Rapid stroke identification and protocol activation Powers et al. (2019); Turc et al. (2019)

Initial care Immediate stroke team activation Reduction of door-to-imaging and door-to-reperfusion times Saver (2006); Meretoja et al.

Clinical assessment Hemodynamic stabilization, neurological assessment, and continuous monitoring Assessing eligibility for reperfusion Powers et al. (2019)

Neuroimaging Non-contrast CT plus CT angiography Rule out hemorrhage and identify large vessel occlusion Campbell et al. (2015); Jovin Thrombolysis eligibility screening Intravenous alteplase administration Early recanalization and penumbra preservation Emberson et al. (2014); Berge Mechanical thrombectomy eligibility screening Clinical and radiological evaluation for endovascular therapy Cerebral reperfusion of occluded large vessels Berkhemer et al. (2015); Goyal et al. (2015)

Extended therapeutic window CT or MRI perfusion for advanced patient selection Expanding therapeutic eligibility Nogueira et al. (2018); Albers Blood pressure control Blood pressure management within target ranges Prevention of hypoperfusion and intracranial hemorrhage Yang et al. (2022); Powers et al. (2019)

Blood glucose control Correction of hyper- or hypoglycemia Minimizing secondary neuronal injury Powers et al. (2019)

Temperature control Prevention and management of hyperthermia Reduction of cerebral metabolism and inflammatory response Chamorro et al. (2016); Dammavalam et al. (2024)

Oxygen saturation maintenance Maintenance of oxygen saturation ≥94% Preserving neuronal viability Powers et al. (2019) Clinical neuroprotection Metabolic, hemodynamic, and inflammatory control Preserving the ischemic penumbra Savitz et al. (2017); Wang et al. (2026)

Stroke Unit Care Admission to a Stroke Unit Mortality reduction and functional improvement Stroke Unit Trialists' Collaboration (2013)

Post-thrombectomy monitoring Serial neurological assessment and complication monitoring Early detection of neurological deterioration Martins et al. (2020); Turc et al. (2019)

Prevention of complications Prophylaxis for VTE, aspiration, and infections Reduction of hospital morbidity Winstein et al. (2016) Early rehabilitation Immediate referral to a multidisciplinary team Maximizing functional recovery Langhorne et al. (2011); Winstein et al. (2016) Source: Compiled by the authors (2026). The studies included in this systematic review demonstrate that physical therapy plays a fundamental role in all phases of the acute ischemic stroke hospital protocol (Table 2). Physiotherapeutic interventions commence upon admission to the Stroke Unit, encompassing early functional assessment, respiratory monitoring, safe mobilization, and the prevention of complications secondary to immobility. It was observed that early mobilization, when performed in an individualized and clinically safe manner, is associated with shorter hospital stays, improved functionality, and greater independence in activities of daily living. Additionally, respiratory physiotherapy techniques helped mitigate pulmonary complications, whereas motor, balance, and gait training programs enhanced neuroplasticity and functional outcomes. Altogether, these findings highlight the necessity of active physiotherapist involvement in specialized multidisciplinary stroke teams, proving vital to the neurological and functional recovery of patients following mechanical thrombectomy.

Table 2: Main physiotherapeutic interventions in the acute ischemic stroke hospital protocol for patients undergoing mechanical thrombectomy, as identified in the systematic review studies. Care Phase Physiotherapist Role Clinical Objective Observed Benefits Key Evidence Hospital admission Initial functional assessment and risk stratification Determine baseline motor and respiratory limitations Individualized rehabilitation planning Winstein et al. (2016); Minelli et al. (2022)

Stroke Unit Respiratory and functional monitoring Early identification of clinical changes Reduced pulmonary complications Winstein et al. (2016)

Bedridden patients Repositioning and therapeutic positioning Prevent pressure injuries and deformities Lower incidence of musculoskeletal complications Langhorne et al. (2011) Acute phase Safe early mobilization Reduce deleterious effects of prolonged bed rest Shorter hospital stay and improved functionality Bernhardt et al. (2015); Langhorne et al. (2018)

Acute phase Passive and active-assisted exercises Preserve joint range of motion Prevention of contractures and stiffness Pollock et al. (2014)

Acute phase Postural control training Improve body stability Reduced fall risk Veerbeek et al. (2014) Acute/Subacute phase Static and dynamic balance training Restore functional independence Enhanced motor performance Veerbeek et al. (2014); Pollock et al. (2014)

Motor deficit Neuromuscular facilitation and motor stimulation Facilitate cortical reorganization Neuroplasticity enhancement Langhorne et al. (2011) Critical patients Preventive respiratory physiotherapy Maintain adequate pulmonary ventilation Reduction of atelectasis and pneumonia Winstein et al. (2016)

Pulmonary secretions Bronchial hygiene techniques Improve mucociliary clearance Lower incidence of respiratory infections Minelli et al. (2022)

Mechanical ventilation Ventilatory management and weaning Optimize gas exchange Increased independence in ADLs Winstein et al. (2016)

Post-thrombectomy Supervised progressive mobilization Early functional recovery Greater locomotor capacity Bernhardt et al. (2015) Gait deficits Assisted gait training Restore mobility Greater locomotor capacity Mehrholz et al. (2017) Motor rehab Muscle strengthening exercises Recovery of strength and function Improved global functional capacity Veerbeek et al. (2014)

Functional rehab Transfer training and basic activities Promote functional independence Reduced post-discharge dependency Pollock et al. (2014)

Discharge planning Family guidance and therapeutic continuity Ensure rehabilitation follow-up Better long-term recovery Winstein et al. (2016); Minelli et al. (2022) Source: Compiled by the authors (2026). Evidence from the analyzed studies confirms that nursing is central to the acute ischemic stroke hospital protocol, performing tasks ranging from initial symptom recognition to discharge planning. Primary responsibilities involve 'Stroke Code' activation, serial monitoring of neurological and hemodynamic status, safe pharmacological administration, and prophylaxis of complications related to hospitalization (Table 3).

The literature demonstrates that clinical surveillance by the nursing team contributes directly to the early detection of neurological deterioration, rigorous control of physiological factors associated with neuroprotection, and a reduction in adverse events. Furthermore, health education and the coordination of multidisciplinary care have proven fundamental in ensuring therapeutic continuity, treatment adherence, and improved functional outcomes following hospital discharge.

Consequently, nursing is established as a cornerstone of modern stroke protocols, actively participating in reperfusion, neuroprotection, and rehabilitation strategies.

Table 3: Main nursing interventions in the acute ischemic stroke hospital protocol for patients undergoing mechanical thrombectomy, as identified in the systematic review studies. Care Phase Nursing Role Clinical Objective Observed Benefits Key Evidence Initial triage Stroke symptom recognition and "Stroke Code" activation Reduce treatment delays Faster door-to-imaging and door-to-needle times Powers et al. (2019); Turc Hospital admission Admission assessment and risk stratification Prioritize eligible patients for reperfusion Enhanced diagnostic and therapeutic speed Powers et al. (2019)

Acute phase Continuous vital signs monitoring Early detection of clinical instability Reduced neurological and cardiovascular complications Powers et al. (2019) Acute phase Serial neurological monitoring (NIHSS, GCS)

Early detection of neurological deterioration Prompt intervention for complications Martins et al. (2020)

Pre-thrombectomy Preparation for diagnostic and therapeutic procedures Ensure patient safety Reduction in procedural delays Turc et al. (2019)

During thrombectomy Assistance to the medical team and clinical monitoring Maintenance of hemodynamic stability Increased procedural safety Nogueira et al. (2018) Blood pressure control Frequent blood pressure monitoring Prevent intracranial hemorrhage and hypoperfusion Better neurological prognosis Yang et al. (2022) Glycemic control Monitoring and correction of glycemic levels Minimize secondary neuronal injury Reduced metabolic adverse events Powers et al. (2019)

Thermal control Temperature monitoring and Reduce hyperthermia Reduced secondary neuronal Chamorro et al. (2016)

antipyretic measures associated with poor outcomes damage Oxygen therapy Saturation control and respiratory support Ensure adequate cerebral oxygenation Preservation of neuronal viability Powers et al. (2019)

Vascular access care Maintenance of catheters and venous access Ensure safe medication administration Lower incidence of infectious complications Winstein et al. (2016)

Aspiration prevention Swallowing assessment and proper positioning Reduce aspiration pneumonia Reduced hospital morbidity Winstein et al. (2016) Pressure injury prevention Repositioning and skin care Preserve skin integrity Reduced immobility-related injuries Stroke Unit Trialists' Collaboration (2013)

VTE prophylaxis Application of prescribed preventive measures Reduce thromboembolic events Reduced hospital mortality Powers et al. (2019) Medication administration Safe execution of medical orders Ensure therapeutic effectiveness Lower incidence of medication errors Winstein et al. (2016) Patient/Family education Guidance on stroke, risk factors, and treatment Promote therapeutic adherence Reduced hospital readmission rates Minelli et al. (2022)

Discharge planning Care coordination and continuity Facilitate hospital-to-home transition Improved functional recovery Royal College of Physicians (2023)

Multiprofessional rehab Integration with PT, SLP, and OT Promote global recovery Enhanced functional outcomes Winstein et al. (2016); Langhorne et al. (2011) Source: Developed by the author (2026).

4.1. Introduction to the Acute Ischemic Stroke Hospital

Care Protocol Acute ischemic stroke (AIS) represents a major neurological emergency in clinical practice, accounting for substantial rates of mortality, functional disability, and socioeconomic burden worldwide. The rapid interruption of cerebral blood flow triggers a cascade of pathophysiological events that can lead to irreversible neuronal death in the absence of early therapeutic intervention. In this context, the implementation of standardized hospital protocols has become one of the most effective strategies to reduce diagnostic delays, optimize clinical decision-making, and improve outcomes for patients affected by this condition (Powers et al., 2019; Campbell & Khatri, 2020) [54, 12].

Over the last few decades, significant advances have occurred in the treatment of acute ischemic stroke, particularly with the consolidation of intravenous thrombolysis and mechanical thrombectomy as reperfusion therapies capable of restoring cerebral blood flow and salvaging the ischemic penumbra. However, the success of these interventions relies directly on the speed and efficiency of hospital care, reinforcing the need for well-structured clinical protocols that are integrated across different healthcare disciplines (Berkhemer et al., 2015; Goyal et al., 2015; Nogueira et al., 2018) [6, 24, 50]. Beyond reperfusion therapies, the adoption of neuroprotective measures constitutes an essential component of modern stroke management. Strategies such as rigorous blood pressure control, maintenance of normoglycemia, prevention of hyperthermia, adequate oxygenation, and continuous neurological monitoring contribute to minimizing secondary brain injury and maximizing the benefits derived from vascular recanalization. Consequently, neuroprotection has come to be considered a complementary and indispensable phase within contemporary acute ischemic stroke management protocols (Chamorro et al., 2016; Savitz et al., 2017; Dammavalam, Aghaebrahim, & Rai, 2024) [17, 59, 19].

Stroke patient care also requires a multidisciplinary approach, involving physicians, nurses, physical therapists, speech-language pathologists, occupational therapists, and other specialized professionals. The integration of these teams enables not only clinical stabilization and acute treatment but also early initiation of rehabilitation, a factor associated with a reduction in complications, shorter hospital stays, and improved long-term functional outcomes (Winstein et al., 2016; Minelli et al., 2022) [70, 42]. Given this scenario, the development of a standardized hospital protocol aims to systematically organize all stages of care, from early symptom identification and 'Stroke Code' activation to cerebral reperfusion, intensive monitoring, neuroprotection, and multidisciplinary rehabilitation. The implementation of these evidence-based measures contributes significantly to improving the quality of care, reducing mortality, and maximizing the functional recovery of patients affected by acute ischemic stroke."

4.2. Standardized Protocol for The Management of Acute

Ischemic Stroke • Objective To standardize hospital care for patients with suspected or confirmed acute ischemic stroke, ensuring early identification, rapid diagnostic confirmation, appropriate indication of intravenous thrombolysis and/or mechanical thrombectomy, application of neuroprotective strategies, and timely initiation of multidisciplinary rehabilitation.

• Target Audience Adult patients with suspected acute ischemic stroke presenting with sudden onset of focal neurological deficits, including motor, sensory, visual, speech, balance, or consciousness impairments.

• Multidisciplinary Team o Emergency physician; o Neurologist; o Radiologist; o Interventional neuroradiologist; o Nurse; o Nursing technician; o Physical therapist; o Speech-language pathologist; o Occupational therapist; o Pharmacist; o Social worker and psychologist (as indicated/required).

• Initial Care Workflow Table 4 Step Action Responsible Professional Triage Recognize stroke signs and activate “Stroke Code” Nursing Initial Assessment ABCDE evaluation, vital signs, capillary blood glucose, and symptom onset time Physician and Nursing Neurological Scale Perform NIHSS and Glasgow Coma Scale (GCS) Physician Neuroimaging Request non-contrast head CT, CT angiography, and/or perfusion imaging (as indicated) Physician / Radiology Therapeutic Decision Assess eligibility for thrombolysis and/or thrombectomy Neurology / Stroke Team Treatment Initiate reperfusion within the shortest possible time Medical Team Monitoring Neurological, blood pressure, glycemic, thermal, and respiratory control Physician / Nursing / Physical Therapy • Immediate Medical Management 1. Confirm symptom onset time or “last known well” time. 2. Evaluate contraindications for intravenous thrombolysis.

3. Order essential laboratory tests without delaying

4. Perform non-contrast head CT to rule out intracranial hemorrhage.

5. Order CT angiography (CTA) in suspected large vessel occlusion.

6. Indicate intravenous thrombolysis for eligible patients.

7. Indicate mechanical thrombectomy for patients with

large vessel occlusion meeting clinical and radiological criteria.

8. Manage blood pressure according to therapeutic targets. 9. Correct significant hypo- or hyperglycemia. 10. Treat fever and maintain normothermia. 11. Maintain oxygen saturation ≥ 94%.

12. Avoid hypotension, hypoxia, hyperthermia, and

• General Criteria for Mechanical Thrombectomy Mechanical thrombectomy should be considered in patients with: • Acute ischemic stroke; • Large intracranial vessel occlusion; • Disabling neurological deficit; • Imaging findings excluding intracranial hemorrhage; • Presence of potentially salvageable brain tissue (penumbra); • Appropriate therapeutic window or patient selection through advanced imaging in the extended window.

• In-Hospital Neuroprotective Strategies Table 5 Strategy Goal/Target Oxygenation Maintain SpO₂ ≥ 94% Blood pressure Avoid hypotension and severe hypertension Temperature Treat fever and maintain normothermia Glycemia Avoid hypo- and hyperglycemia Hydration Maintain euvolemia Head of bed Elevate to 30° when indicated Swallowing Assess before oral intake Mobilization Initiate after clinical stability Neurological monitoring Perform serial NIHSS/Glasgow assessments Complication prevention Prevent aspiration, VTE, pressure injuries, and infections • Nursing Care Nursing staff shall act in triage, "Stroke Code" activation, continuous monitoring, safe medication administration, and blood pressure, glycemic, and thermal control. Additionally, nursing responsibilities include the prevention of aspiration pneumonia, pressure injuries, and complications related to immobility.

• Physical Therapy Care The physical therapy team must conduct early respiratory and motor assessments, implement therapeutic positioning, prevent pulmonary complications, and provide progressive mobilization, postural control training, strengthening exercises, assisted gait training, and functional discharge planning.

• Multidisciplinary Rehabilitation Rehabilitation must be initiated early, following clinical stabilization, and involves physical therapy, speech-language pathology, occupational therapy, nursing, medicine, nutrition, and psychology. The primary objective is to reduce disability, prevent complications, and promote functional independence.

• Post-Reperfusion Monitoring Following thrombolysis and/or mechanical thrombectomy, the patient must remain in a monitored unit or Stroke Unit, with: o Serial neurological assessments; o Strict blood pressure control; o Surveillance for intracranial hemorrhage; o Glycemic and thermal control; o Swallowing assessment; o Prevention of respiratory and thromboembolic complications; o Follow-up neuroimaging as clinically indicated.

• Discharge Criteria Discharge should be planned following clinical and neurological stability, the establishment of a secondary prevention plan, family education, prescription of a rehabilitation program, optimization of vascular risk factors, and referral for outpatient follow-up. • Quality Indicators Table 6 Indicator Target Door-to-Physician time ≤ 10 minutes Door-to-Imaging time ≤ 20 minutes Door-to-Needle time ≤ 60 minutes Door-to-Puncture time As fast as possible Swallowing assessment before oral intake 100% Rehabilitation initiation after stability Within 24–48 hours Discharge on secondary prevention 100% Referral to rehabilitation services 100% • Final Considerations The acute ischemic stroke hospital protocol must integrate rapid diagnosis, cerebral reperfusion, clinical neuroprotection, and multidisciplinary rehabilitation. Coordinated efforts among physicians, nursing staff, physical therapists, and other healthcare professionals are essential to reduce mortality, minimize sequelae, and improve functional outcomes for patients.

5. Discussion

The results of this systematic review demonstrate that the implementation of structured hospital protocols for acute ischemic stroke care is directly associated with reduced mortality, decreased functional disability, and improved clinical outcomes. The consolidation of intravenous thrombolysis and, notably, mechanical thrombectomy has transformed stroke management over the last two decades, enabling previously unattainable rates of cerebral reperfusion and significantly expanding the possibilities for neurological recovery (POWERS et al., 2019; TURC et al., 2019) [54, 65]. The studies analyzed demonstrate that mechanical thrombectomy is currently the standard of care for patients with large intracranial vessel occlusion. Clinical trials such as MR CLEAN, ESCAPE, SWIFT PRIME, EXTEND-IA, and REVASCAT have shown consistent benefits in functional independence and reduced disability at three-month follow-up, consolidating the superiority of the endovascular approach compared to clinical treatment alone (BERKHEMER et al., 2015; CAMPBELL et al., 2015; GOYAL et al., 2015; SAVER et al., 2015; JOVIN et al., 2015) [6, 15, 24, 61, 30]. Furthermore, the DAWN and DEFUSE-3 trials have extended the therapeutic window for cases selected via advanced neuroimaging, allowing a greater number of patients to benefit from mechanical reperfusion (NOGUEIRA et al., 2018; ALBERS et al., 2018) [50, 1]. However, despite the advances observed in vascular recanalization, several studies have indicated that successful reperfusion does not always result in satisfactory neurological recovery. This finding reinforces the importance of secondary injury resulting from processes of excitotoxicity, neuroinflammation, oxidative stress, and ischemia-reperfusion injury, mechanisms that remain active even after the restoration of cerebral blood flow (CHAMORRO et al., 2016; SAVITZ et al., 2017) [17, 59]. In this context, neuroprotective strategies emerge as complementary tools capable of enhancing the benefits of mechanical thrombectomy and preserving brain areas that remain viable.

The literature analyzed demonstrated that clinical measures considered neuroprotective are already part of the routine in modern stroke protocols. Rigorous control of blood pressure, blood glucose, body temperature, and oxygenation has been associated with reduced cerebral infarct expansion and improved functional outcomes (POWERS et al., 2019; YANG et al., 2022) [54, 71]. Although several pharmacological agents have been investigated over the years, clinical results still remain limited when compared to the benefits observed in experimental models. Recent studies suggest that the combination of neuroprotective therapies and early reperfusion may represent one of the primary areas for future development in the treatment of acute ischemic stroke (HILL et al., 2020; WANG et al., 2026) [28, 68]. Another relevant aspect identified in this review was the importance of organizational structure through Stroke Units. Data showed that patients treated in specialized centers exhibit lower mortality, fewer hospital complications, and a higher probability of functional recovery compared to those treated in conventional units (STROKE UNIT TRIALISTS’ COLLABORATION, 2013) [62]. These results reinforce that therapeutic success depends not only on available technology but also on the efficiency of care workflows and the integration among involved professionals. Nursing stands out as a fundamental element for the success of hospital protocols. Rapid symptom identification, Stroke Code activation, continuous monitoring of neurological and hemodynamic parameters, and the prevention of hospital-related complications have proven to be determinant for the safety and effectiveness of the treatment. The continuous involvement of the nursing team allows for the early detection of neurological deterioration and contributes directly to the implementation of neuroprotective measures recommended by international guidelines (WINSTEIN et al., 2016; ROYAL COLLEGE OF PHYSICIANS, 2023) [70, 57]. Likewise, physical therapy plays an indispensable role throughout the entire care process. Studies have shown that early mobilization, progressive motor training, respiratory management, and the prevention of complications associated with immobility significantly contribute to patients' functional recovery. Furthermore, the early stimulation of cerebral neuroplasticity promotes neural reorganization and maximizes the gains achieved through reperfusion therapies (LANGHORNE; BERNHARDT; KWAKKEL, 2011; POLLOCK et al., 2014; VEERBEEK et al., 2014) [32, 52, 67]. The concept of multidisciplinary care has also been widely consolidated in the literature. Integration among neurologists, intensivists, nurses, physical therapists, speech-language pathologists, occupational therapists, and other professionals allows for a more comprehensive approach to patient needs, favoring both neurological recovery and social and functional reintegration after hospital discharge (WINSTEIN et al., 2016; MINELLI et al., 2022) [70, 42].

Finally, the results reinforce that time remains one of the primary prognostic determinants in acute ischemic stroke. The concept of "time is brain" remains current, demonstrating that delays at any stage of care significantly reduce the benefits of cerebral reperfusion and increase the likelihood of permanent disability (SAVER, 2006; MERETOJA et al., 2014; RIBO et al., 2016) [60, 41, 56]. Thus, efficient hospital protocols, combined with neuroprotective strategies and early rehabilitation, constitute the fundamental pillars for optimizing clinical outcomes in acute ischemic stroke.

6. Final Considerations

This systematic review demonstrated that mechanical thrombectomy represents one of the most significant evolutions in the treatment of acute ischemic stroke, providing high rates of cerebral reperfusion and better functional outcomes when performed early and in appropriately selected patients. However, optimal neurological recovery does not depend exclusively on vascular recanalization; it is strongly influenced by the implementation of neuroprotective strategies and the quality of multidisciplinary care provided throughout the entire hospital stay.

The evidence analyzed indicates that neuroprotective measures based on hemodynamic, metabolic, and respiratory control play a fundamental role in preserving the ischemic penumbra and reducing secondary brain damage. Furthermore, the integrated performance of medical, nursing, and physical therapy teams has proven essential for preventing complications, ensuring continuous clinical monitoring, and facilitating the early initiation of functional rehabilitation.

The results also reinforce the importance of Stroke Units and standardized hospital protocols as tools capable of reducing the time to reperfusion, improving care safety, and increasing the chances of functional independence after a cerebrovascular event. In this context, the integration of rapid diagnosis, mechanical thrombectomy, neuroprotection, and multidisciplinary rehabilitation must be considered an indispensable component of modern stroke care systems. Finally, it is observed that further research is necessary to deepen the understanding of specific neuroprotective therapies associated with mechanical thrombectomy, particularly regarding their clinical efficacy, applicability across different populations, and impact on long-term outcomes. The consolidation of these strategies could contribute significantly to the refinement of hospital protocols and to the reduction of the global burden of acute ischemic stroke.