Perfusion Imaging in Acute Stroke for EVT Eligibility: Past Glory or Promise for the Future? (Debate)
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Perfusion Imaging in Acute Stroke for EVT Eligibility: Past Glory or Promise for the Future? (Debate)
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About this listen
Perfusion imaging has revolutionized acute stroke care by enabling tissue-based selection of treatment strategies. Historically, reperfusion treatments like thrombolysis were limited to strict time windows based on the assumption that salvageable brain tissue (the ischemic penumbra) existed only briefly. However, advanced imaging studies showed that some patients maintain viable penumbra beyond these limits.
Perfusion imaging (with CT or MRI) distinguishes ischemic "core" from salvageable "penumbra," guiding decisions for both thrombolysis and endovascular thrombectomy (EVT) while also improving our understanding of mechanistic processes to maintain the viability of penumbra, such as quantifying collateral status. Over the past two decades, key clinical trials validated this approach – from early MRI mismatch studies to landmark trials (EXTEND-IA, DAWN, DEFUSE 3) that extended thrombectomy up to 24 hours for selected patients. Today, perfusion imaging is central to acute stroke decision-making, allowing physicians to "think in terms of tissue, not time."
The debates in this session will review emerging frontiers for perfusion imaging, like medium-vessel occlusions and patients with large ischemic cores, and extending the time window, where perfusion-based criteria may still play an important role in the treatment paradigm. The objective is to provide stroke physicians with a comprehensive understanding of how perfusion imaging will drive future advances in recanalization therapy.