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Images in Neurology |

Altered Brain Computed Tomography Perfusion in Patients With Fluctuating Lacunar Syndrome and Normal Magnetic Resonance Imaging

Salvatore Rudilosso, MD1; Xabier Urra, MD, PhD1,2; Oscar Chirife, MD3; Ángel Chamorro, MD, PhD1,2,4
[+] Author Affiliations
1Functional Unit of Cerebrovascular Diseases, Hospital Clinic, Barcelona, Spain
2Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
3Department of Radiology, Hospital Clinic, Barcelona, Spain
4Department of Medicine, School of Medicine, University of Barcelona, Barcelona, Spain
JAMA Neurol. 2016;73(3):348-349. doi:10.1001/jamaneurol.2015.4026.
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This article describes 2 cases where computed tomography perfusion showed acute ischemic lesions not visible on diffusion-weighted imaging.

We present the cases of an 83-year-old woman and a 53-year-old man who presented to the emergency service with acute right hemiparesis and right ataxic-hemiparesis within 3 hours from symptom onset. The nonenhanced computed tomography (CT) scan was normal while the CT perfusion (CTP) scan showed a delay in time maps in the left pons and in the left thalamus, respectively (Figure). The first patient was treated with intravenous thrombolysis and partially recovered whereas the second patient recovered spontaneously. In both cases, magnetic resonance imaging within 24 hours of admission did not show any acute ischemic lesion on diffusion-weighted imaging (DWI) (Figure). Both patients had progression of the initial focal deficit (3 days and 1 day after admission, respectively), and a repeated magnetic resonance image (Figure) demonstrated hyperintensities on DWI in the left paramedian and thalamoperforator territories, matching with the previous CTP abnormalities and consistent with mature infarctions.

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Figure.
Computed Tomography Perfusion (CTP) and Diffusion-Weighted Imaging (DWI) Studies of the 2 Patients

Time-to-drain maps of the CTP study show delayed perfusion in a perforator artery territory as red spots. The first DWI was normal in both patients while a second DWI showed hyperintensities matching the CTP abnormalities.

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