AAN 2026 | The shift from time-based to tissue-based decision-making for thrombolysis and thrombectomy

We’re in a really exciting era in stroke care. No longer do we ask ourselves how long has it been since the patient’s symptoms started, but instead we ask ourselves is there brain tissue that we can potentially save? Is there viable yet at-risk brain tissue that we can hopefully protect from infarction with treatment with thrombolysis and thrombectomy. Our new guidelines ask us to assess the status of brain tissue and not time to make these decisions. And so when we’re trying to teach people about the most effective ways to identify candidates for thrombolysis and thrombectomy, we really want people to focus on, is the onset of the patient’s symptoms known or not known? And therefore, are they in a traditional or more extended window of treatment? We can use new tools like CT perfusion and DWI flair mismatch to tell us if someone still has salvageable brain tissue. And so in our acute stroke course at the American Academy of Neurology, this meeting, we really focused on helping people have an evidence-based approach to treating with these therapies, because that’s what the guidelines are all about. And we want to help them realize that you can use tissue status with things like CT ASPECT score, CT perfusion, and DWI flair mismatch to identify those patients who have at-risk tissue that’s not yet dead and can most benefit from reperfusion therapy.

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