Experience with CT perfusion scanning (CTP) in treating wake up strokes

Marigold, Richard and Hlaing, S (2022) Experience with CT perfusion scanning (CTP) in treating wake up strokes. p. 54 . (doi:10.1177/17474930221142512).

Abstract

Introduction: CTP with artificial intelligence is now available in many
UK hospitals, and some patients with wake-up symptoms and unclear
onset time benefit from thrombolysis using CTP.
Method: We describe our experience of cases using RAPID AI and CTP
outside historic time windows.
Results: 72 year old with hemianopia, right hemiparesis, and visuospatial
neglect. CTA/CTP showed a 25ml occipital penumbra (T max >6.0s volume)
with no core (CBF<30% volume) and an occluded left PCA.
Thrombolysed at 7hrs 15min and NIHSS 16 - 6.
76 year old presented with dysphasia and right hemiparesis. CTP showed
42ml left frontotemporal penumbra, no core. Thrombolysed at 9hrs after
last well, NIHSS 6-3.
82 year old wake up hemianopia and right hemiparesis, CTP 37ml temporo-
occipital penumbra, no core, thrombolysed at 6hrs, NIHSS 8-1.
92 year old awoke with ataxic hemiparesis, previous multiple comorbidity.
CT, CTA, CTP no infarct, LVO or penumbra. Not thrombolysed given
frailty, but a subsequent dwMRI showed a small thalamic infarct.
72 year old awoke with right leg weakness and dysphasia NIHSS 6,
CT,CTA,CTP no infarct, LVO or penumbra. Not thrombolysed. dwMRI
high up left frontal infarct missed by CTP.
Conclusion: We saw clinical improvements with no adverse outcomes
including symptomatic haemorrhage in 3 wake up patients with thrombolysis
with a penumbra but no core infarction on CTP. Small deep and
higher up anterior cerebral artery (ACA) infarcts may be missed, and
dwMRI with FLAIR looking for a mismatch should be considered in
patients presenting with pure lacunar and ACA territory syndromes.

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