Usefulness of computed tomography perfusion in treatment of an acute stroke patient with unknown time of symptom onset

A 43-year-old Caucasian male with history of mechanical mitral valve was found down outside a recreational park shortly after daybreak. Examination on arrival to the emergency department revealed altered mental status, right hemiplegia, forced leftward gaze, and complete aphasia. Patient was ineligible for tissue plasminogen (TPA) therapy due to unknown time of symptom onset. Computed tomography angiogram (CTA) revealed occlusion of the left middle cerebral artery (MCA) with acute thrombus (Figure 1). Computed tomography perfusion scan (CTP) revealed a large ischemic penumbra with no evidence of infarcted brain tissue (Figure 2). The patient was taken for emergent endovascular therapy with successful retrieval of left MCA thrombus. The patient had almost complete resolution of symptoms with a pre-discharge National Institute of Health Stroke Scale of 1. History prior to discharge revealed that the patient was non-compliant and had been off of his warfarin therapy for months prior to the stroke. The patient was discharged home on warfarin and statin therapy.