What is the acute management of ischemic stroke?

IV alteplase within 4.5 hours of symptom onset for eligible patients. Tenecteplase non-inferior for LVO. Mechanical thrombectomy for large vessel occlusion within 6 hours (extended to 24 hours with favorable perfusion imaging). Door-to-needle target <60 minutes. Blood pressure management: permissive hypertension unless thrombolysis (<185/110) or extreme elevation. Aspirin within 24-48 hours. Admit to stroke unit. Early rehabilitation.