OBJECTIVES: Current guidelines do not support the use of computed tomography perfusion (CTP) in stroke, except when identifying the penumbra during an extended treatment window. Therefore, this study aimed to define the yield of CTP in diagnosing a stroke diagnosis beyond the imaging of the penumbra in the hyperacute phase (0-6 h) and an extended time window (6-24 h). MATERIALS AND METHODS: All consecutive patients with acute onset of symptoms within a 24-h window underwent CTP imaging. The diagnostic value of CTP was calculated against the clinical and radiological diagnoses of stroke. A positive CTP result was determined by the presence of either a core or penumbra on the RAPID summary. Clinical diagnoses corresponded to discharge diagnoses of stroke. A radiological diagnosis was established if early ischemic changes [Alberta Stroke Program Early CT Score (ASPECTS) <10] were observed on the baseline CT scan, acute infarction was confirmed on follow-up imaging, or symptomatic occlusion was evident on baseline CTA. RESULTS: Between November 2018 and November 2019, 585 consecutive patients with an acute neurological deficit underwent multimodal CT imaging. A total of 500 patients (85%) were included, where 274 (55%) were within the hyperacute phase, 153 (31%) had a radiological diagnosis of stroke, and 122 (24%) had a clinical diagnosis of stroke. CTP yielded positive results only in patients with a confirmed stroke (positive predictive value and specificity of 100%). When CTP results were negative, 43% of the cases turned out to stroke mimics. Patients with stroke mimics were younger (66 ± 17 vs. 73 ± 13) and had lower scores on the National Institutes of Health Stroke Scale [median 0; interquartile range (IQR) 0-2 vs. median 4; IQR 2-6] compared to patients with CTP-negative strokes. CONCLUSION: In our study, CTP consistently indicated brain ischemia; therefore, in stroke management, CTP is most beneficial when it yields a positive result. A positive CTP result should prompt adequate stroke management actions without any delay. Conversely, a negative CTP result necessitates the consideration of both stroke and non-stroke diagnoses.

Department of Neurology Faculty of Medicine St Anne's University Hospital Brno Masaryk University Brno Czechia

International Clinical Research Centre St Anne's University Hospital Brno Brno Czechia

Zobrazit více v PubMed

Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al. . Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. (2018) 378:708–18. 10.1056/NEJMoa1713973 PubMed DOI PMC

Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. . Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. (2015) 372:1009–18. 10.1056/NEJMoa1414792 PubMed DOI

Ma H, Campbell BCV, Parsons MW, Churilov L, Levi CR, Hsu C, et al. . Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke. N Engl J Med. (2019) 380:1795–803. 10.1056/NEJMoa1813046 PubMed DOI

Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. . Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. (2018) 378:11–21. 10.1056/NEJMoa1706442 PubMed DOI

Mikulik R, Bar M, Cernik D, Herzig R, Jura R, Jurak L, et al. . Stroke 20 20: implementation goals for intravenous thrombolysis. Eur Stroke J. (2021) 6:151–9. 10.1177/23969873211007684 PubMed DOI PMC

Bendszus M, Fiehler J, Subtil F, Bonekamp S, Aamodt AH, Fuentes B, et al. . Endovascular thrombectomy for acute ischaemic stroke with established large infarct: multicentre, open-label, randomised trial. Lancet. (2023) 402:1753–63. 10.1016/S0140-6736(23)02032-9 PubMed DOI

Huo X, Ma G, Tong X, Zhang X, Pan Y, Nguyen TN, et al. . Trial of endovascular therapy for acute ischemic stroke with large infarct. N Engl J Med. (2023) 388:1272–83. 10.1056/NEJMoa2213379 PubMed DOI

Haršány M, Bar M, Cerník D, Herzig R, Jura R, Jurák L, et al. . One-stop management to initiate thrombolytic treatment on the computed tomography table: adoption and results. J Stroke. (2021) 23:437–9. 10.5853/jos.2021.00878 PubMed DOI PMC

Gibson LM, Whiteley W. The differential diagnosis of suspected stroke: a systematic review. J R Coll Phys Edinb. (2013) 43:114–8. 10.4997/JRCPE.2013.205 PubMed DOI

Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. . Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. (2019) 50:e344–418. 10.1161/STR.0000000000000211 PubMed DOI

Masterson K, Vargas MI, Delavelle J. Postictal deficit mimicking stroke: role of perfusion CT. J Neuroradiol. (2009) 36:48–51. 10.1016/j.neurad.2008.08.006 PubMed DOI

Gelfand JM, Wintermark M, Josephson SA. Cerebral perfusion-CT patterns following seizure. Eur J Neurol. (2010) 17:594–601. 10.1111/j.1468-1331.2009.02869.x PubMed DOI

Kim SJ, Kim DW, Kim HY, Roh HG, Park JJ. Seizure in code stroke: Stroke mimic and initial manifestation of stroke. Am J Emerg Med. (2019) 37:1871–5. 10.1016/j.ajem.2018.12.051 PubMed DOI

Strambo D, Rey V, Rossetti AO, Maeder P, Dunet V, Browaeys P, et al. . Perfusion-CT imaging in epileptic seizures. J Neurol. (2018) 265:2972–9. 10.1007/s00415-018-9095-1 PubMed DOI

Pallesen LP, Lambrou D, Eskandari A, Barlinn J, Barlinn K, Reichmann H, et al. . Perfusion computed tomography in posterior circulation stroke: predictors and prognostic implications of focal hypoperfusion. Eur J Neurol. (2018) 25:725–31. 10.1111/ene.13578 PubMed DOI

Rudilosso S, Urra X, San Román L, Laredo C, López-Rueda A, Amaro S, et al. . Perfusion deficits and mismatch in patients with acute lacunar infarcts studied with whole-brain CT perfusion. AJNR Am J Neuroradiol. (2015) 36:1407–12. 10.3174/ajnr.A4303 PubMed DOI PMC

Biesbroek JM, Niesten JM, Dankbaar JW, Biessels GJ, Velthuis BK, Reitsma JB, et al. . Diagnostic accuracy of CT perfusion imaging for detecting acute ischemic stroke: a systematic review and meta-analysis. Cerebrovasc Dis. (2013) 35:493–501. 10.1159/000350200 PubMed DOI

Czap AL, Sheth SA. Overview of imaging modalities in stroke. Neurology. (2021) 97:S42–51. 10.1212/WNL.0000000000012794 PubMed DOI PMC

Rapillo CM, Dunet V, Pistocchi S, Salerno A, Darioli V, Bartolini B, et al. . Moving from CT to MRI paradigm in acute ischemic stroke: feasibility, effects on stroke diagnosis and long-term outcomes. Stroke. (2024) 55:1329–38. 10.1161/STROKEAHA.123.045154 PubMed DOI PMC

Wintermark M, Sanelli PC, Albers GW, Bello J, Derdeyn C, Hetts SW, et al. . Imaging recommendations for acute stroke and transient ischemic attack patients: a joint statement by the American Society of Neuroradiology, the American College of Radiology, and the Society of NeuroInterventional Surgery. AJNR Am J Neuroradiol. (2013) 34:E117–27. 10.3174/ajnr.A3690 PubMed DOI PMC

Simonsen CZ, Madsen MH, Schmitz ML, Mikkelsen IK, Fisher M, Andersen G. Sensitivity of diffusion- and perfusion-weighted imaging for diagnosing acute ischemic stroke is 97.5%. Stroke. (2015) 46:98–101. 10.1161/STROKEAHA.114.007107 PubMed DOI

Chen P, Pan Y, Wang J, Hui J, Gao R, Lin G, et al. . The value of computed tomography perfusion deficit volumes in acute isolated brainstem infarction. Front Neurol. (2023) 14:1233784. 10.3389/fneur.2023.1233784 PubMed DOI PMC

Lin K, Do KG, Ong P, Shapiro M, Babb JS, Siller KA, et al. . Perfusion CT improves diagnostic accuracy for hyperacute ischemic stroke in the 3-hour window: study of 100 patients with diffusion MRI confirmation. Cerebrovasc Dis. (2009) 28:72–9. 10.1159/000219300 PubMed DOI

Rai AT, Carpenter JS, Peykanu JA, Popovich T, Hobbs GR, Riggs JE. The role of CT perfusion imaging in acute stroke diagnosis: a large single-center experience. J Emerg Med. (2008) 35:287–92. 10.1016/j.jemermed.2007.08.071 PubMed DOI

Eastwood JD, Lev MH, Wintermark M, Fitzek C, Barboriak DP, Delong DM, et al. . Correlation of early dynamic CT perfusion imaging with whole-brain MR diffusion and perfusion imaging in acute hemispheric stroke. AJNR Am J Neuroradiol. (2003) 24:1869–75. PubMed PMC

Esteban JM, Cervera V. Perfusion CT and angio CT in the assessment of acute stroke. Neuroradiology. (2004) 46:705–15. 10.1007/s00234-004-1235-x PubMed DOI

Pepper EM, Parsons MW, Bateman GA, Levi CR, CT. perfusion source images improve identification of early ischaemic change in hyperacute stroke. J Clin Neurosci. (2006) 13:199–205. 10.1016/j.jocn.2005.03.030 PubMed DOI

van der Hoeven EJ, Dankbaar JW, Algra A, Vos JA, Niesten JM, van Seeters T, et al. . Additional diagnostic value of computed tomography perfusion for detection of acute ischemic stroke in the posterior circulation. Stroke. (2015) 46:1113–5. 10.1161/STROKEAHA.115.008718 PubMed DOI

The e-STROKE Study: The Design of a Prospective Observational Multicentral Study