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Inoue et al. Vessel Plus 2021;5:11 Vessel Plus
DOI: 10.20517/2574-1209.2020.99

Review Open Access

Expanding the therapeutic window in acute ischemic
stroke by advanced imaging

Manabu Inoue, Kazunori Toyoda

Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan.
Correspondence to: Dr. Manabu Inoue, Department of Cerebrovascular Medicine, National Cardiovascular Center, 6-1 Kishibe-
shimmachi, Suita, Osaka 564-8565, Japan. E-mail: gakinoue@ncvc.go.jp

How to cite this article: Inoue M, Toyoda K. Expanding the therapeutic window in acute ischemic stroke by advanced imaging.
Vessel Plus 2021;5:11. http://dx.doi.org/10.20517/2574-1209.2020.99

Received: 23 Dec 2020 First Decision: 18 Jan 2021 Revised: 20 Jan 2021 Accepted: 26 Jan 2021 Published: 7 Feb 2021

Academic Editor: Aaron S. Dumont Copy Editor: Xi-Jun Chen Production Editor: Yue-Yue Zhang

Abstract
The treatment in acute ischemic stroke has shown extensive improvement in these recent years by new
Received: First Decision: Revised: Accepted: Published: x endovascular devices and advanced imaging. Advanced imaging is mainly led by perfusion imaging and has
been powered by automated analyzing software. In this manuscript, we describe the history and the technology
Science Editor: Copy Editor: Production Editor: Jing Yu
of perfusion imaging, including parameters and analyzing methods that have evolved from positron emission
tomography and single-photon computed tomography to computed tomography perfusion and magnetic
resonance imaging perfusion. The immense clinical advantage of advanced imaging is expansion of the therapeutic
window by various mismatch assessments. Of these, perfusion-weighted imaging - core mismatch has managed
to demonstrate the evidence in randomized control trials. A unique understanding of conventional imaging such as
diffusion-weighted image - fluid-attenuated inversion recovery mismatch has also played a role in expanding the
therapeutic window to wake-up strokes or unwitnessed strokes. In this article, these mismatch assessed trials are
described with future insights.

Keywords: Ischemic stroke, perfusion imaging; penumbra; cerebral blood flow, thrombolysis, tissue plasminogen
activator, alteplase, CT perfusion, MR perfusion, randomized trial, wake-up stroke

INTRODUCTION
In recent stroke diagnosis, imaging selection for achieving appropriate therapy is as essential as traditional
neurological examination. Advanced imaging in stroke has dramatically influenced and explored the

© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0
International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
sharing, adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as long
as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made.

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