Current perspective in acute ischemic stroke: net water uptake and imaging-guided selection as bridges to personalized, tissue-based care

Acute ischemic stroke diagnosis is shifting to individualized, tissue-based treatment decision-making. Recent randomized trials have expanded thrombectomy to patients with large ischemic lesions, although outcomes vary across studies—with MRI-selected cohorts (e.g., LASTE) positive and CT-only selection (e.g., TESLA) neutral in its primary endpoint (1–4). Neuroprotection remains relevant despite neutral/negative results in ESCAPE-NEXT and CHARM, as ultra-early strategies applied in the FRONTIER trial suggest promise (5–7). Tenecteplase has emerged as a practical, effective thrombolytic alternative to alteplase, and trials are testing adjuvant intra-arterial lysis (e.g., TECNO) (8). Conversely, evidence for thrombectomy in low NIHSS stroke and distal/medium vessel occlusions is not yet available or has been neutral to negative in recent randomized trials, underscoring that treatment selection matters (9, 10). This Perspective comment highlights net water uptake (NWU) as a prototypical CT-based edema biomarker alongside novel imaging techniques that may refine selection–stratifying risk, forecasting complications, and identifying patients likely to benefit from reperfusion or anti-edema strategies. We conclude with an outlook on AI-enabled, CT-first workflows that deliver rapid tissue profiling–penumbral imaging, automated early edema imaging such as NWU, and collaterals–to guide personalized acute stroke therapy.