Computed Tomography Perfusion-Based Decision Making for Acute Ischemic Stroke-Missing the Mismatch.

Area of Science:

• Neurology
• Radiology
• Cardiovascular Medicine

Background:

• Mechanical thrombectomy is a key treatment for acute ischemic stroke.
• Patient selection is crucial for successful outcomes.
• Computed tomography perfusion (CTP) is frequently used for patient assessment.

Observation:

• An 80-year-old man with acute ischemic stroke had an M2 occlusion.
• CTP indicated a large ischemic core and minimal penumbra, leading to withholding mechanical thrombectomy.
• The patient recovered fully within 24 hours, with imaging showing a small stroke.

Findings:

• Significant discrepancies were observed between CTP and MRI findings.
• CTP results incorrectly suggested a large infarct, precluding potentially beneficial thrombectomy.
• The case demonstrates CTP's potential unreliability in early stroke assessment.

Implications:

• CTP should not be the sole criterion for excluding patients from mechanical thrombectomy in the early intervention window.
• MRI or clinical-radiological mismatch should be prioritized for patient selection.
• CTP may be valuable in borderline cases, such as wake-up strokes or extended time windows.