Advanced Imaging in the Era of Tissue-Based Treatment for Acute Ischemic Stroke—a Practical Review

Purpose of the review: Advanced imaging is now used to identify acute ischemic stroke (AIS) patients for treatment with tissue plasminogen activator or mechanical thrombectomy, who are either out of the traditional treatment window or have an unknown last known well time. Current guidelines recommend adapting the complex inclusion criteria used in the clinical trials to provide optimal individual patient decisions in clinical practice. This review aims to facilitate such integration by organizing the available data in a practical clinical context. Recent findings: We review two clinical vignettes of advanced imaging for the treatment of AIS, the rationale for using the imaging criteria with correlations from the gold-standard quantitative oxygen-15 positron emission tomography imaging to understand cerebral ischemia and magnetic resonance imaging, and its limitations. Summary: Advanced stroke imaging is required to treat patients with AIS in the extended time window. Understanding the rationale, differences in the individual study criteria and limitations of imaging can help the treating physician in incorporating advanced stroke imaging-based clinical trials in clinical practice.