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An 82 yo man with aphasia and right-side weakness performed NCCT and single-phase CTA from 2.5 h from symptoms onset in spoke center that showed a large parenchymal hypodensity referring to acute ischemic stroke with ASPECT score of 6 (Insula, M2, M3, M6 segments) due to distal M1 cerebral artery occlusion. 3.5 h later, neuroimaging study protocol with NCCT, multi-phase CT-Angiography and CT-Perfusion in hub center was repeated. CT-Perfusion was realized with OLEA Perfusion Software that define total hypoperfused tissue with Tmax > 6 s and infarct core with rCBF < 40%. A spontaneous partial vascular recanalization with leptomeningeal vasodilatation occurred and CTP showed a little ischemic core (3,8 ml) and large penumbra (108,5 ml). 3 days after, NCCT uphold the ischemic core size. This case shows a typical Perfusion Scotoma with underestimation of ischemic core volume > 6 h from symptom onset due to early reperfusion from partial recanalization as well as luxury perfusion [1, 2] (Fig. 1).
Neuroimaging study protocol in spoke and hub center: NCCT with ASPECT score of 6 and distal M1 cerebral artery occlusion. (A) NCCT, mCTA and CTP > 6 h from symptom onset with spontaneous recanalization and ischemic core underestimation due to luxury perfusion (B,C). NCCT at 3 days uphold a large ischemic core size (D)
References
Abrams K, Dabus G (2022) Perfusion Scotoma: A Potential Core Underestimation in CT Perfusion in the Delayed time window in patients with acute ischemic stroke. AJNR Am J Neuroradiol 43(6):813–816. https://doi.org/10.3174/ajnr.A7524
Nagar VA, McKinney AM, Karagulle AT et al (2009) Reperfusion phenomenon masking acute and subacute infarcts at dynamic perfusion CT: confirmation by fusion of CT and diffusion-weighted MR images. AJNR Am J Neuroradiol 193:1629–38 (CrossRef Medline)
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Busto, G., Scola, E. & Fainardi, E. Computed tomography perfusion ischemic core underestimation: a perfusion scotoma case. Neurol Sci 45, 827–829 (2024). https://doi.org/10.1007/s10072-023-07139-3
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DOI: https://doi.org/10.1007/s10072-023-07139-3