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Acute stroke imaging selection for mechanical thrombectomy in the extended time window: is it time to go back to basics? A review of current evidence
  1. Joachim Fladt1,2,
  2. Christopher D d’Esterre1,
  3. Raed Joundi1,
  4. Connor McDougall1,
  5. Henrik Gensicke2,
  6. Philip Barber1
  1. 1 Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
  2. 2 Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland
  1. Correspondence to Dr Philip Barber, Departments of Clinical Neurosciences, Radiology and Community Health Sciences, University of Calgary, Calgary, AB T2N 4N1, Canada; pabarber{at}ucalgary.ca

Abstract

Treatment with endovascular therapy in the extended time window for acute ischaemic stroke with large vessel occlusion involves stringent selection criteria based on the two landmark studies DAWN and DEFUSE3. Current protocols typically include the requirement of advanced perfusion imaging which may exclude a substantial proportion of patients from receiving a potentially effective therapy. Efforts to offer endovascular reperfusion therapies to all appropriate candidates may be facilitated by the use of simplified imaging selection paradigms with widely available basic imaging techniques, such as non-contrast CT and CT angiography. Currently available evidence from our literature review suggests that patients meeting simplified imaging selection criteria may benefit as much as those patients selected using advanced imaging techniques (CT perfusion or MRI) from endovascular therapy in the extended time window. A comprehensive understanding of the role of imaging in patient selection is critical to optimising access to endovascular therapy in the extended time window and improving outcomes in acute stroke. This article provides an overview on current developments and future directions in this emerging area.

  • stroke
  • interventional

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Footnotes

  • Twitter @joachimfladt

  • Contributors Fladt Joachim: Conception of the work; literature search; analysis and interpretation of data; drafting and revising the manuscript; final approval of the version to be published d'Esterre Christopher D.: Drafting and revising the manuscript Joundi Raed: Drafting and revising the manuscript McDougall Connor: Drafting and revising the manuscript Gensicke Henrik Drafting and revising the manuscript Barber Philip A.: Conception of the work; analysis and interpretation of data; drafting and revising the manuscript; final approval of the version to be published.

  • Funding JF is supported by a personal research grant from the Swiss National Science Foundation (Reference: P400PM_194456).

  • Competing interests CM, CD, and PB are cofounders of Andromeda Medical Imaging Inc.; PB reports consulting fees for Ablynx Pharmaceutical, and a Canadian Institutes of Health Research grant.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.