Interventional neuroradiology of stroke, still not dead

Since the National Institute of Neurological Disorders and Stroke trial, intravenous thrombolysis has been gaining wide acceptance as the modality of treatment for acute embolic stroke, with a current therapeutic window of up to 4.5 h. Both imaging [with either magnetic resonance imaging (MRI) or computed tomography (CT)] and interventional techniques (thrombolysis and/or thrombectomy) have since improved and provided us with additional imaging of the penumbra using CT or MRI and more advanced thrombolysis or thrombectomy strategies that have been embraced in many centers dealing with patients with acute cerebral ischemia. These techniques, however, have come under scrutiny due to their accrued healthcare costs and have been questioned following major recent studies. These studies basically showed that interventional techniques were not superior to the traditional intravenous thrombolysis techniques and that penumbra imaging could not determine what patients would benefit from more aggressive (i.e., interventional) treatment. We discuss this in the light of the latest developments in both diagnostic and interventional neuroradiology and point out why further studies are needed in order to define the right choices for patients with acute stroke. Indeed, these studies were in part conducted with suboptimal patient recruitment strategies and did not always use the latest interventional techniques available today. So, while these studies may have raised some relevant questions, at the same time, definitive answers have not been given, in our opinion.