Computed Tomography Perfusion in Suspected Ischemic Stroke: Patient-Related Pitfalls and Practical Clues Beyond Automated Interpretation

The management of suspected ischemic stroke has evolved significantly, largely due to advancements in imaging technologies such as Computed Tomography Perfusion (CTP). This narrative review aims to delineate the practical applications and limitations of CTP in acute stroke evaluation, particularly in challenging scenarios. It is organized around illustrative clinical and imaging cases regarding small subcortical infarctions, posterior fossa ischemia, abnormal reference hemispheres, chronic steno-occlusive disease, the simultaneous involvement of multiple vascular territories, luxury perfusion, diaschisis, and systemic hemodynamic abnormalities. We discuss the core–penumbra paradigm, emphasizing the need for accurate interpretation of perfusion maps to guide therapeutic decisions. While automated CTP analyses enhance diagnostic efficiency, they can overlook critical patient-specific factors and exhibit variability in performance across different software platforms. Limitations in detecting small infarcts, particularly in lacunar strokes, highlight the necessity for qualitative visual assessments alongside quantitative data. Individualized case evaluations are crucial, as discrepancies between automated readings and qualitative interpretations can influence the management of single cases. Furthermore, we propose an integrated approach that combines automated assessments with human expertise to improve diagnostic precision and treatment efficacy. Future research should focus on refining CTP methodologies and enhancing their applicability in diverse clinical contexts to optimize patient management in acute ischemic stroke situations.