ARTICLE IN PRESS

Case Studies

Different Perfusion Patterns in a Patient with Acute
Ischemic Stroke
Salvatore Rudilosso, MD,* Carlos Laredo, MSc,*,† Xabier Urra, MD, PhD,*,† and
Ángel Chamorro, MD, PhD*,†

A 29-year-old male patient with aphasia and mild weakness of the right arm arrived
at the emergency room 4 hours after symptom onset. The computed tomography perfusion showed a typical delay in the time-based maps in the left occipital
lobe and another hyperperfused area in the left frontal lobe. The follow-up magnetic resonance imaging confirmed cortical ischemic lesions in both areas. This
case shows that besides hypoperfusion, hyperperfusion can also be found in the
first stages of acute stroke, and it is highly suggestive of established ischemic lesions.
Key Words: Ischemic stroke—CT perfusion—hyperperfusion—reperfusion.
© 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Case Presentation
We present a case of a 29-year-old male patient, with
no cardiovascular risk factors other than smoking habit,
who presented with sudden motor aphasia, weakness,
and hypoesthesia of the right arm. On his arrival at the
emergency service 4 hours after symptom onset, he was
improving, but the examination still showed mild right
upper limb weakness. Nonenhanced computed tomography (CT) scan showed loss of cortical gray-white
differentiation in part of the left frontal lobe (Fig 1). The
perfusion maps showed a typical image of delay in timebased maps and reduced flow in the left occipital lobe
and a hyperperfused area with no delay and increased
flow in the left frontal lobe (Fig 1). All vessels were patent
on CT angiography. The patient did not receive any acute

From the *Functional Unit of Cerebrovascular Diseases, Hospital
Clínic, Barcelona, Spain; and †Institut d’Investigacions Biomèdiques
August Pi i Sunyer, Barcelona, Spain.
Received December 21, 2016; accepted February 20, 2017.
Address correspondence to Xabier Urra, MD, PhD, Institute of
Neurosciences, 170 Villarroel, 08036 Barcelona, Spain. E-mail:
xurra@clinic.cat; @xabierurra.
1052-3057/$ - see front matter
© 2017 National Stroke Association. Published by Elsevier Inc. All
rights reserved.
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2017.02.025

reperfusion therapy as he was almost recovered after
neuroimaging. The follow-up magnetic resonance imaging
72 hours later showed ischemic lesions on diffusionweighted imaging that matched both areas with altered
perfusion (Fig 1). The full etiologic workup showed only
a patent foramen ovale, but no deep venous thrombosis
or prothrombotic disorders. The patient fully recovered
and was discharged on antiplatelet therapy.

Discussion
Cortical hyperperfusion has been seen not only in stroke
mimics such as hypermetabolism in focal seizures,1 but
also in acute stroke, especially after thrombolysis.2,3 This
case report demonstrates that local hyperperfusion can
be present in the very first stages of ischemic stroke and
that different patterns of perfusion can be found at the
same time. Hyperperfused areas in acute ischemic stroke
seem to reflect tissue that is already infarcted. Actually
in this case, the nonenhanced CT showed signs of established ischemia inside the hyperperfused area. We
speculate that the hyperperfusion may be the result of
spontaneous reperfusion in brain vessels with impaired
autoregulatory capacity due to ischemia. Regional differences in collateral circulation and in the ischemic
threshold may explain why hypo- and hyperperfused areas
co-exist after cerebral ischemia. The prognostic value of

Journal of Stroke and Cerebrovascular Diseases, Vol. ■■, No. ■■ (■■), 2017: pp ■■–■■

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S. RUDILOSSO ET AL.

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Figure 1. Nonenhanced computed tomography (CT),
CT perfusion, and follow-up diffusion-weighted imaging
(DWI) studies.
The first row shows a hypoperfused lesion with delay
in the time-to-peak (TTP) map and a reduced cerebral
blood flow (CBF) area. The second row shows a
hyperperfused lesion characterized by a normal TTP
map and a hyperperfused area in the CBF map. The
nonenhanced CT shows early ischemic changes in this
area. In both cases, an ischemic lesion was found in
the follow-up DWI. The white circles point out the described findings.

these findings is still controversial: early positron emission tomography studies described that spontaneous
hyperperfusion in ischemic stroke could be related to better
outcome,4 but later studies showed that hyperperfusion
was associated with hemorrhagic transformation.3 From
a practical point of view, clinicians should be aware that
in a patient with acute neurological deficits, hyperperfused
areas on CT perfusion that respect a vascular territory
are highly suggestive of established ischemic lesions.

References
1. Payabvash S, Oswood MC, Truwit CL, et al. Acute CT
perfusion changes in seizure patients presenting to the

emergency department with stroke-like symptoms:
correlation with clinical and electroencephalography
findings. Clin Radiol 2015;70:1136-1143. doi:10.1016/
j.crad.2015.06.078.
2. Shahi V, Fugate JE, Kallmes DF, et al. Early basal ganglia
hyperperfusion on CT perfusion in acute ischemic stroke:
a marker of irreversible damage? AJNR Am J Neuroradiol
2014;35:1688-1692. doi:10.3174/ajnr.A3935.
3. Yu S, Liebeskind DS, Dua S, et al. Postischemic
hyperperfusion on arterial spin labeled perfusion MRI is
linked to hemorrhagic transformation in stroke. J Cereb
Blood Flow Metab 2015;35:630-637. doi:10.1038/
jcbfm.2014.238.
4. Marchal G, Furlan M, Beaudouin V, et al. Early
spontaneous hyperperfusion after stroke. A marker of
favourable tissue outcome? Brain 1996;119:409-419.