The most substantial advance in stroke therapy has been the routine management of patients in stroke units (SUs), with stroke-dedicated beds and staff. SU treatment is effective in reducing mortality and disability in about 20 % of patients, independently from age, stroke subtype, and severity. Although the precise components of SU management responsible for the effectiveness of SUs are unclear, monitoring, early mobilization, and general adherence to best practice could improve stroke outcome [9].

Recombinant tPA (rtPA) is the only evidence-based effective therapy for acute ischemic stroke. The major adverse effect of thrombolysis is symptomatic intracerebral hemorrhage, seen in about 6–7 % of cases, but which is even lower in the European (SITS MOST) study population. Although the publication data of ECASS III study widened the therapeutic time window from 3 to 4.5 h, the number of patients who could receive rtPA treatment is small. However, substantial uncertainties about the efficacy in reducing death and improving functional outcome still remain regarding the longest time window, the efficacy in people older than 80 years, and the role of other potential influencing factors (i.e., stroke subtype, use of antiplatelet before stroke). A recent meta-analysis on 7012 patients seems to support the treatment efficacy independently of age or stroke severity and in at least a part of patients treated within 6 h [10].

The available evidence from trials performed with different methodological approaches, including “bridging” and different devices, does not show that endovascular therapy achieves superior outcomes in comparison to intravenous thrombolysis for the acute treatment of ischemic stroke patients [11].

Decompressive surgery, removal of part of the skull and duraplasty, has been proposed as a way to control raised intracranial pressure and reduce shifts of swollen brain tissue after stroke. The results of randomized trials show that decompression reduces death rate (ARR 38 %, 15–60; p = 0.002) and slightly improves the functional outcome, defined as an mRS score of 5 or 6 (mRS: 4 moderately severe disability; mRS 5: severe disability) in patients with space-occupying hemispheric infarction treated within 48 h of stroke onset. Seventy-eight percent of survival was observed in patients submitted to decompressive surgery versus 29 % of the medically treated. The modified Rankin Score (mRS) was ≤4 in 75 % of patients in the surgery group versus 24 % in controls; mRS was ≤3 in 43 % versus 21 % in the surgically and conservatively treated group, respectively [12]. There is no evidence that this operation improves functional outcome when it is delayed for up to 96 h after stroke onset. Recent guidelines support the use of decompressive craniotomy in patients with swelling stroke who continue to deteriorate neurologically. Patients older than 60 years also benefit from this treatment [13]. The 3-year follow-up data of HAMLET study, which is the largest randomized trial in this field [14, 15], reported that surgical patients had a lower case fatality rate than controls, whereas the risk of a poor outcome did not differ between groups.

Pharmacological and physical cooling studies do not reduce the risk of death or dependency (OR 0.9; 95 % CI, 0.6–1.4) in patients with acute stroke [16].