Tailored Treatment of Acute Ischemic Stroke: A Narrative Review of Evidence-Based Strategies by Imaging Type and Thrombectomy Availability

Stroke is a leading cause of disability and the second cause of death in adults. Moreover, the incidence of stroke is continuously rising. Acute reperfusion therapies (ARTs) have revolutionized stroke medicine and have altered the natural course of acute ischemic stroke. However, these treatments are ultimately offered to only a minority of acute ischemic stroke (AIS) patients, primarily due to delays in presentation. The use of advanced imaging has partially increased eligibility for ART; nevertheless, a large proportion of AIS patients remain untreated. In addition, many stroke centers lack readily available advanced imaging, sometimes lacking even computed tomography angiography. In these settings, several recent studies have sought to simplify the imaging prerequisites and criteria for the administration of ARTs. In this review, we discuss the possible treatment options for AIS patients presenting in different time points, according to type of imaging availability and mechanical thrombectomy availability. Our aim is to provide evidence-based recommendations, but also to analyze emerging data supporting the individualized, off-label use of ART without the aid of advanced imaging.