Page 93 - Read Online

Lim et al. Vessel Plus 2021;5:34 Vessel Plus
DOI: 10.20517/2574-1209.2021.44

Review Open Access

The advanced imaging-guided approach to acute

ischemic stroke in the extended reperfusion time
window

2,3
1,3
2,3
2,3
Andy Lim , Channa Senanayake , Benjamin Clissold , Thanh Phan , Henry Ma 2,3
1
Department of Emergency Medicine, Monash Medical Centre, Melbourne 3168, Australia.
2
Department of Neurology, Monash Medical Centre, Melbourne 3168, Australia.
3
School of Clinical Sciences, Monash University, Melbourne 3800, Australia.
Correspondence to: Prof. Henry Ma, Department of Neurology, Monash Medical Centre, 246 Clayton Road, Victoria 3168,
Australia. E-mail: henry.ma@monashhealth.org
How to cite this article: Lim A, Senanayake C, Clissold B, Phan T, Ma H. The advanced imaging-guided approach to acute
ischemic stroke in the extended reperfusion time window. Vessel Plus 2021;5:34. https://dx.doi.org/10.20517/2574-
1209.2021.44
Received: 9 Mar 2021 First Decision: 30 Apr 2021 Revised: 5 May 2020 Accepted: 18 May 2021 Published: 23 Jun 2021

Academic Editor: Elisa Francesca Maria Ciceri Copy Editor: Xi-Jun Chen Production Editor: Xi-Jun Chen

Abstract
Evaluation and treatment of acute ischemic stroke has undergone significant advancement since the 1990s, when
acute systemic reperfusion with intravenous alteplase became the first approved method for achieving reperfusion.
Until recently, 4.5 h after stroke onset appeared to be the maximum time window in which positive results from
thrombolysis can be achieved. However, the advent of advanced imaging modalities, including multimodal
magnetic resonance imaging and computed tomography perfusion has allowed clinicians to refine the evaluation of
these patients by delineating areas of infarcted tissue, areas of potentially salvageable tissue given timely
reperfusion, and areas of benign oligemia. Early work in extending the time window beyond this historical limit of
4.5 h has culminated in four positive trials that demonstrate the benefit of acute mechanical or systemic
reperfusion therapy in an extended time window of up to 24 h, using advanced imaging criteria for patient
selection. The implications of the success of advanced imaging suggest use of these modalities for disposition
decisions and selection of greater numbers of patients for reperfusion but add complexity to individual patient
evaluation. Despite this, many questions remain unanswered, including the best choice of thrombolysis agent,
whether we can extend the time window further to 24 h, and the optimal combination of mechanical
thrombectomy and bridging therapy in the late time window in patients with or without large vessel occlusion.

© 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.

www.vpjournal.net