Imaging-based selection in acute ischemic stroke trials - a quest for imaging sweet spots

Ischemic stroke is a very heterogeneous disease that limits the efficacy of acute stroke treatments. Future trials will require advanced imaging to select patients for specific treatments. The most well-established imaging tools are the use of CT to exclude hemorrhage and diffusion-weighted MRI to demonstrate ischemia. While perfusion imaging is one option for patient selection, it has unresolved issues, including standardization and validation, that limit its value. As an alternative to mismatch when addressing stroke, one needs to know the size of the initial irreversible lesion (core), the presence and site/extent of occlusion (clot), and presence of leptomeningeal back filling and Willisian filling (collaterals). These can be summarized as the 3C approach of core, clot, and collateral interpretation, which together can represent an imaging sweet spot, particularly for time-efficient endovascular treatment trial design.