There is a great need for new treatments for acute ischemic stroke that will achieve greater rates of arterial recanalization and increase the population of patients who may benefit. Of several approaches under investigation, intra-arterial therapy (IAT) is the farthest along in clinical development, but experience has shown that the increased rates of recanalization achieved are not always translated to improved patient outcomes. Proper patient selection, allied to efficient strategies aiming at faster recanalization and reperfusion, may result in better clinical outcomes and more rational use of therapeutic resources. While high-tech multimodal imaging has the great promise of identifying hypoperfused but still viable brain tissue, a number of clues suggest that relatively low-tech approaches similar to those that were used to demonstrate the efficacy of systemic thrombolysis, and which have emphasized the key role of time and clinical factors such as age, glucose, stroke severity, and infarct on noncontrast CT scan, deserve greater study as an efficient way to optimize IAT. Eventually it will be a combination of predictors that will enable us to most precisely identify the best patients for IAT and any other new revascularization therapies.
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