Expanding boundaries in stroke treatment: New horizons in revascularization strategies and critical decision-making

Ischemic stroke is one of the leading causes of mortality and long-term disability worldwide, emphasizing the need for rapid and effective acute management. Revascularization therapies are critical to this strategy, demanding swift intervention. Intravenous thrombolysis (IVT) with alteplase (ALT) was traditionally recommended within 4.5 h from symptom onset for acute ischemic stroke (AIS) patients. However, landmark studies, such as ECASS IV, EXTEND, and EPITHET have demonstrated that IVT may be extended up to 9 h in select patients, identified through perfusion imaging with computed tomography or magnetic resonance imaging, enabling differentiation of viable, at-risk brain tissue in the ischemic penumbra from the infarct core. This allows treatment in cases with favorable “mismatch” profiles, Similarly, endovascular procedures for large vessel occlusions (LVOs) were initially recommended within 6 h, but trials, such as DEFUSE-3 and DAWN have established efficacy for thrombectomy up to 16 – 24 h from the last known well time, using perfusion imaging to guide patient selection. These advancements prioritize tissue viability over rigid temporal thresholds. Despite significant progress, optimal revascularization strategies for AIS remain uncertain in complex clinical contexts, such as posterior circulation strokes, large infarct core AIS, distal vascular occlusions, and mild clinical deficit LVO-related AIS. Recent research aims to address these gaps, expanding reperfusion criteria and exploring new thrombolytic agents with potential benefits over ALT. Collectively, these studies aim to refine and broaden therapeutic criteria, improving outcomes for a wider AIS patient population.