Objective:

NA

Background:

Perfusion neuroimaging has become crucial to acute stroke treatment due to its ability to identify areas of reduced perfusion and salvageable tissue. In select situations, current guidelines recommend the use of perfusion imaging to identify patients with a favorable profile for candidates for mechanical thrombectomy. The applicability of perfusion findings in other acute stroke scenarios is less established.

Design/Methods:

NA

Results:

A 77 year old female with hypertension and obesity presented with altered mental status to the emergency room as a pre-arrival stroke alert after being found unarousable by her partner in bed. Her last known well time was 2 hours prior to presentation. On arrival she had a blood pressure of 127/92 and was afebrile. Neurologic exam showed a decreased level of alertness. She did not respond to loud auditory stimuli. She grimaced to sternal rub and was able to briefly follow requests to give a thumbs up bilaterally. She produced no speech and withdrew all extremities from protopathic stimulation. Reflexes were 2+ and symmetric. Initial head computed tomography (CT) showed no abnormality. CT perfusion showed a perfusion deficit of 4mL in the posterior circulation. CT angiogram of the head and neck showed no abnormality. She was administered intravenous alteplase and admitted. MRI of the brain showed diffusion restriction in bilateral thalami. No embolic source was identified and she was placed on a long term cardiac monitor. One month following discharge she continued to have persistent aphasia, impaired cognition, and required 24-hour care.

Conclusions:

The clinical utility of perfusion neuroimaging extends beyond current clinical guidelines. Proficiency in study interpretation and correlation between patient presentation and neuroanatomical structures affected by perfusion deficits may allow additional stroke patients to receive treatment, particularly in atypical presentations of stroke such as altered mental status.