Where Does the Signal Go? Technical Challenges of CT Perfusion in Lacunar and Infratentorial Stroke

Background/Objectives: Computed tomography perfusion is widely used in acute ischemic stroke, but its performance is less reliable for lacunar and infratentorial infarcts. This technical review examines the acquisition and processing factors that influence their detectability. Methods: A targeted technical review of PubMed/MEDLINE, Scopus, and Web of Science was performed, focusing on acquisition, reconstruction, vascular input selection, deconvolution, filtering, spatial sampling, automated classification, posterior circulation stroke, and lacunar infarction. Results: Detectability depends on lesion size and contrast, posterior fossa artifacts, spatial and temporal resolution, vascular curve quality, mathematical stabilization, and automated thresholds. Larger cerebellar infarcts may remain visible, whereas brainstem, deep cerebellar, and perforator lesions are more vulnerable. Temporal maps and direct review of parametric images may reveal abnormalities absent from automated summaries. Conclusions: This technical review shows that computed tomography perfusion should be interpreted as a derived estimate rather than a direct representation of cerebral hemodynamics. Negative automated findings do not exclude lacunar or infratentorial infarction when clinical suspicion remains high.