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

J A Molad¹, M Findler¹, E Auriel²

¹Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.

Journal of Stroke and Cerebrovascular Diseases : the Official Journal of National Stroke Association

|March 21, 2017

Summary

Computed tomography perfusion (CTP) may inaccurately exclude patients from mechanical thrombectomy. This case highlights the need for MRI or clinical-radiological mismatch evaluation in acute ischemic stroke treatment, especially in early time frames.

Keywords:

Acute ischemic stroke CT perfusion endovascular thrombectomy penumbra

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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.