Controversies in Imaging of Patients With Acute Ischemic Stroke: AJR Expert Panel Narrative Review

The development of reperfusion therapies has profoundly impacted stroke care, initially with the advent of IV thrombolytic treatment and, more recently, with the development and refinement of endovascular treatment (EVT). Progress in neuroimaging has supported the paradigm shift of stroke care, and advanced neuroimaging now has a fundamental role in triaging patients for both IV thrombolytic treatment and EVT. As the standard of care for acute ischemic stroke (AIS) evolves, controversies remain in certain clinical scenarios. This article explores the use of multimodality imaging for treatment selection of patients with AIS in the context of recent guidelines, highlighting controversial topics and providing guidance for clinical practice. The results of major randomized trials supporting EVT are reviewed. The advantages and disadvantages of CT, CTA, MRI, and MRA in stroke diagnosis are summarized with attention to level 1 evidence supporting the role of vascular imaging and perfusion imaging. Patient selection is compared between approaches based on time thresholds and physiologic approaches based on infarct core measurement using imaging. Moreover, various imaging approaches to core measurement are described. As ongoing studies push treatment boundaries, advanced imaging is expected to help identify a widening range of patients who may benefit from therapy.

Automated summary

The development of reperfusion therapies has significantly impacted stroke care through the use of IV thrombolytic treatment and EVT, with neuroimaging playing a crucial role in patient triage and treatment selection. This article examines the use of multimodality imaging for AIS patients, highlighting controversial topics and providing guidance for clinical practice, while also reviewing major randomized trials supporting EVT. Advanced imaging is expected to further expand patient selection and treatment possibilities as ongoing studies push the boundaries of stroke care.