Computed Tomography Perfusion-Based Decision Making for Acute Ischemic Stroke-Missing the Mismatch.
The emerging use of mechanical thrombectomy for acute ischemic stroke treatment focuses on the importance of patient selection. Computed tomography perfusion (CTP) is one of widely used techniques. However, the accuracy and reliability of this modality is in debate among vascular neurologists. We present a case of an 80-year-old man admitted because of acute ischemic stroke. CT angiography demonstrated left proximal M2 occlusion. As CTP demonstrated signs of large ischemic core with no significant penumbra, mechanical thrombectomy was not performed following tPA administration. Twenty-four hours after thrombolysis, the patient was neurologically intact. Both non-contrast CT and magnetic resonance imaging (MRI) demonstrated small stroke involving the left caudate. Differences between CTP and MRI diffuse-weighted imaging were previously described. However, in the presented case, these differences were brought to extreme, precluding endovascular treatment. In our opinion, this case emphasizes why CTP should not be used for patient exclusion among patients in the early time frame for intervention. Such patients should be evaluated by MRI or by clinical-radiological mismatch only. CTP may have a role in selecting patients for endovascular intervention in borderline circumstances such as prolonged time window, wake-up stroke, etc.
Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.
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JA
Molad
Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel.
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M
Findler
Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel. Electronic address: eitanman1@gmail.com.
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E
Auriel
D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000628:therapy; D002560:Cerebrovascular Circulation; D000066491:Clinical Decision-Making; D038524:Diffusion Magnetic Resonance Imaging; D005343:Fibrinolytic Agents / Q000008:administration & dosage; D006801:Humans; D008297:Male; D064847:Multimodal Imaging; D018579:Patient Selection; D055420:Perfusion Imaging / Q000379:methods*; D011237:Predictive Value of Tests; D020521:Stroke / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000628:therapy; D017131:Thrombectomy; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
Acute ischemic stroke; CT perfusion; endovascular thrombectomy; penumbra