 Matthew J. Gounis |
 Ajay Wakhloo |
Endovascular treatment of acute ischemic stroke, despite exciting technology developments over the past two decades, suffered a major setback this year. Three randomized trials showed no clinical benefit for intra-arterial treatments as compared with standard medical therapy.1-3 As with all trials, each has certain limitations—well beyond the scope of this commentary. Amid the swirling controversy to explain these outcomes, one general consensus emerges around patient selection.4 Despite advanced imaging techniques that may be able to identify the best candidates for intra-arterial reperfusion therapy, the unfortunate reality is that, on average, 875 to 1446 minutes are consumed between the time from brain imaging to groin-puncture prior to a successful recanalization. The group at the University of Wisconsin recognized the urgent need to develop the ability to image brain function in the angiosuite, representing a fundamental paradigm shift. They first developed an approach using C-arm conebeam CT (CBCT) to acquire CBV maps7,8 that showed good agreement with multidetector perfusion CT. This novel work inspired us, and coupled with the capability of our research facility with an integrated MR and angiography unit, we sought to quantitatively compare C-arm CBCT-derived CBV measurements with MR apparent diffusion coefficient maps and histology. We reported in this paper that despite qualitative agreement of the CBV maps with other measures of brain infarction, quantitative comparisons require further improvements in the detector physics and general approach for reliable clinical application.
Not deterred, many researchers have tried to solve the ultimate challenge in C-arm-based CBCT perfusion imaging: the measurement of cerebral blood flow.9-14 These developments in research labs around the world may ultimately create a future where patients with stroke will have diagnostic penumbral imaging and potential intra-arterial treatment integrated in the same suite, creating a truly comprehensive stroke center. Much work remains for robust development and characterization of these techniques, but there is a vision to make stroke a treatable disease rather than a rehabilitation disease.