J Neurocrit Care.  2024 Dec;17(2):79-83. 10.18700/jnc.240028.

Discrepancies in computed tomography (CT) perfusion and CT angiography imaging following stroke in a patient post-heart transplant on extracorporeal membrane oxygenation: a case report

Affiliations
  • 1Neurosurgical Service, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
  • 2Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA

Abstract

Background
Extracorporeal membrane oxygenation (ECMO) is a critical life-support intervention for severe cardiopulmonary failure. Venoarterial (VA)-ECMO presents unique challenges in neuroradiological assessment due to hemodynamic alterations and the presence of imaging artifacts.
Case Report
This case report describes an adult post-heart transplant patient on peripheral VA-ECMO who developed left-sided hemiparesis, suggestive of cerebrovascular events. While our patient developed multifocal ischemic infarcts, the initial computed tomography perfusion (CTP) imaging indicated hypoperfusion of the entire right hemisphere. Given the discrepancy in the patient’s clinical assessment, which was suggestive of a more circumscribed right hemispheric involvement, and the CTP findings, subsequent digital subtraction angiography was performed, which demonstrated adequate vascular filling with no large vessel occlusion.
Conclusion
These findings highlight the diagnostic complexities of ECMO-related artifacts, even in the presence of neurological complications that can mimic true perfusion deficits and potentially lead to misdiagnosis.

Keyword

Stroke; Extracorporeal membrane oxygenation; Computed tomography angiography; Computed tomography perfusion

Figure

  • Fig. 1. Computed tomography perfusion (CTP) imaging results. Initial CTP imaging displayed regions of hypoperfusion in the right hemisphere, indicated by the color-coded overlays. The pink areas indicate regions with severely reduced cerebral blood flow (CBF <30%), while the green areas represent regions with prolonged time to maximum (Tmax >6.0 seconds). The mismatch volume between these regions indicates potential penumbral tissue that could be salvageable. The imaging artifacts caused by the extracorporeal membrane oxygenation hemodynamics are evident, complicating the differentiation between true perfusion deficits and artifactual findings.

  • Fig. 2. Digital subtraction angiography (DSA) results. DSA results of the same patient demonstrated adequate vascular filling and perfusion in the right hemisphere, with no evidence of large vessel occlusion.


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