Use of computed tomography perfusion for acute stroke in routine clinical practice: complex scenarios, mimics, and artifacts

Background: Computed tomography perfusion is becoming widely accepted and used in acute stroke treatment. Computed tomography perfusion provides pathophysiological information needed in the acute decision making. Moreover, computed tomography perfusion shows excellent correlation with diffusion-weighted imaging and perfusion-weighted sequences to evaluate core and penumbra volumes. Multimodal computed tomography perfusion has practical advantages over magnetic resonance imaging, including availability, accessibility, and speed. Nevertheless, it bears some limitations, as the limited accuracy for small ischemic lesions or brainstem ischemia. Interpretation of the computed tomography perfusion maps can sometimes be difficult. The stroke neurologist faces complex or atypical cases of cerebral ischemia and stroke mimics, and needs to decide whether the "lesions" on computed tomography perfusion are real or artifact. Aims: The purpose of this review is, based on clinical cases from a comprehensive stroke center, to describe the added value that computed tomography perfusion can provide to the stroke physician in the acute phase before a treatment decision is made.