The computed tomographic (CT) or magnetic resonance imaging (MRI) findings of early cerebral ischemia are literally, and figuratively, shades of gray in decision making regarding the triage of patients with acute ischemic stroke for revascularization. The subtleties and areas of uncertainty on imaging of this dynamic process, where an arterial occlusion is mitigated by collateral perfusion in the brain, defy concrete rules or thresholds that are equally consequential across individual patients.1 Imaging criteria, whether more than one-third of the middle cerebral artery territory, Alberta Stroke Program Early CT (ASPECT) scores, or core ischemic volumes, may be broadly applied to a population without properly ascertaining the relative effect of reperfusion in discrete scenarios. The categorical exclusion of large ischemic cores may have been warranted in prior trials to establish the role of endovascular therapy, yet uncertainties or shades of gray abound in the daily triage of patients with such lesions. Lesion size, topography, and context lose all dimensions when imaging is reduced to a single number or patient profiles are categorically defined. Rebello et al2 challenge the historical tenet of imaging selection that eliminates the only therapeutic opportunity for patients with large ischemic cores and large mismatch imaging profiles to avoid devastating outcomes. Their article builds on mounting data from a variety of approaches with CT and MRI that question the way we use imaging and the process of how we consider optimal therapeutic strategies for patients with stroke.3,4
Liebeskind DS. Lesion Size and Perspective in Acute Ischemic Stroke: Shades of Gray. JAMA Neurol. 2017;74(1):15–17. doi:10.1001/jamaneurol.2016.4275
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