Abstract
Background: Lacunar stroke is a common form of ischaemic stroke with mechanisms poorly understood compared to large vessel stroke. Access to gold standard MRI is often limited in the acute setting. Acute diagnosis of lacunar stroke is difficult with conventional CT, as non-contrast CT and CT angiography have poor sensitivity. Previous studies have demonstrated only low to moderate sensitivity of CT perfusion (CTP). Aims: To test the accuracy of thin-slice CTP to detect lacunar stroke and compare the clinical and radiological characteristics to better understand the limitations of CTP for diagnosis of lacunar stroke. Methods: We reviewed thin-slice CTP (slice thickness <=3mm) of cases presenting with an acute lacunar syndrome without large/medium vessel occlusion, or perfusion lesion detected by automated analysis. Cases presented to two comprehensive stroke centres in Sydney and Newcastle, NSW, Australia, between 2019 and 2022. CTP was reviewed by two independent reviewers, blinded to follow-up MRI but not the clinical syndrome. CTP and DWI were registered to a standard template and DWI lesions were manually segmented. CTP was further reviewed adjacent to DWI, and raw CTP values within the lesion was calculated. Results: We reviewed 394 cases of acute lacunar syndrome including 82 stroke mimics, 48 infratentorial and 250 supratentorial infarcts. Overall sensitivity was 76% and varied by infarct location. Sensitivity was lowest for brainstem (46%), moderate for thalamic (69%) and high for infarcts within the lenticulostriate perforator territory (84%). Factors associated with reduced sensitivity include small infarct volume, increased noise, or artefact, and infratentorial location. Conclusion: Thin-slice CTP has high sensitivity for detection of supratentorial lacunar infarcts however is more susceptible to noise and imaging artefact than larger infarcts. Advanced processing techniques show promise to improve overall diagnosis of lacunar stroke.
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