The Continued Role and Value of Imaging for Acute Ischemic Stroke

Advances in neuroimaging in the last 2 decades have revolutionized the management of acute ischemic stroke (AIS). Here we review the development of computed tomography (CT) and magnetic resonance imaging (MRI) modalities used to guide treatment of patients with AIS characterized by large vessel occlusion. In particular, we highlight recent randomized trials and their patient selection methodologies to detail the progression of these selection paradigms. With advanced imaging, distinction between at-risk penumbra and ischemic core in AIS may be performed using either CT or MRI. While limitations exist for methodologies to quantify core and penumbra, commercially available fully automated software packages provide useful information to guide treatment decisions. Randomized controlled trials implementing perfusion imaging to patient selection algorithms have demonstrated marked success in improving functional outcomes in patients with large vessel occlusions. As such, imaging has become a vital aspect of AIS treatment in selecting patients who may benefit from mechanical thrombectomy.