Abstract
In acute stroke management, time window has been rigidly used as a guide for decades and the reperfusion treatment is only available in the first few limited hours. Recently, imaging-based selection of patients has successfully expanded the treatment window out to 16 and even 24 h in the DEFUSE 3 and DAWN trials, respectively. Recent guidelines recommend the use of imaging techniques to guide therapeutic decision-making and expanded eligibility in acute ischemic stroke. A tissue window is proposed to replace the time window and serve as the surrogate marker for potentially salvageable tissue. This article reviews the evolution of time window, addresses the advantage of a tissue window in precision medicine for ischemic stroke, and discusses both the established and emerging techniques of neuroimaging and their roles in defining a tissue window. We also emphasize the metabolic imaging and molecular imaging of brain pathophysiology, and highlight its potential in patient selection and treatment response prediction in ischemic stroke.
Highlights
Stroke is the worldwide leading cause of death and adult disability
We review the most recently advances in metabolic imaging, which may greatly facilitate routine clinical applications to guide optimal therapy decision for acute ischemic stroke as well as subacute or chronic stroke with permanent large vessel occlusion
Emerging evidence from recent clinical trials have recognized that tissue viability defined by the imaging modalities might be a more precise and reliable surrogate marker than time window [159]
Summary
Stroke is the worldwide leading cause of death and adult disability. More than 80% of all strokes are caused by brain ischemia, which results from obstruction of one or more cerebral arteries. In the past decade, accumulating clinical trials have shown that with the patients selecting by neuroimaging, the time window for reperfusion has been iteratively extended (Table 1) [3,4,5,6] The results of these studies revolutionize the field and suggested that “tissue window” might be more personalized than a “time window” to guide precision medicine for ischemic stroke [7, 8]. In 1981, Baron et al observed decreased CBF and increased oxygen extraction fraction (OEF) in an ischemic stroke patient by PET and coined this modality as “misery perfusion” which indicated potential viable tissue [36] This area with increased OEF was the original definition of penumbra. The extent of penumbra is dynamic and time dependent process, which
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