Recanalization for large vessel stroke

Precision medicine, the initiative to replace a one-size-fits-all approach designed for the average patient with treatments tailored to account for unique differences among individuals, shifts paradigms across many fields of medicine. Within neurology, the treatment of ischemic stroke due to large vessel occlusions (LVO) offers a compelling illustration. In recent years, reproducible measurements of clinical deficit burden (e.g., NIH Stroke Scale), combined with multimodal imaging to identify LVO and to estimate the volumes of irrecoverable infarct and potentially salvageable tissue, have created a system to rapidly individualize treatment within various time windows.¹ Implicitly, there is no average stroke. Individual intrinsic differences in the flow capacity of collateral vessels, degree of chronic ischemic disease, ischemic preconditioning, oxidative stress tolerance, microvascular blood flow regulation, and other factors influence each patient's response to treatment interventions such as thrombolysis, thrombectomy, or hemodynamic augmentation. For example, the adequacy of collateral blood flow in patients with LVO predicts the likelihood of neurologic worsening and differs markedly among patients.² Collateral flow partially determines the degree of volume mismatch between infarct core and at-risk penumbra, as well as the success of endovascular treatment.³ Chronic ischemic disease in the form of leukoaraiosis predicts symptomatic hemorrhage and poor outcomes after intravenous thrombolysis and endovascular thrombectomy, and the hyperacute response to oxidative stress predicts infarct growth and final infarct volume.^4,5