Neuroimaging in acute stroke: choosing the right patient for neurointervention

Although the non-contrast computed tomography head continues as the sole mandatory imaging technique before intravenous thrombolysis, the increased availability of advanced infarct/penumbral imaging techniques and confidence in their use have led many to adopt them into routine practice--most particularly before intra-arterial interventions. Computed tomography versus magnetic resonance-based routes to imaging the cerebral vasculature, cell death, and parenchymal perfusion have differing advantages in terms of speed, availability, exposures to contrast and radiation, sensitivity, and resolution. Continued refinement and future developments, such as the ability to quantitate perfusion, promise to lead to tailored treatment protocols that respect the individual variations in anatomy, physiology, and pathology. This should lead both to an extension of treatment to patients currently excluded by rigid time windows and the avoidance of futile therapies and their associated morbidities.