Understanding CT Perfusion in Acute Ischemic Stroke: How Algorithms Shape Perfusion Maps

CT perfusion (CTP) is widely used in acute ischemic stroke imaging, particularly for treatment selection beyond conventional time windows. However, automated perfusion maps are not direct measurements of irreversible tissue injury, but estimates shaped by deconvolution strategy, temporal correction, dispersion handling, and software-specific thresholds. This review provides a clinically oriented explanation of how CTP algorithms influence the estimation of ischemic core and hypoperfused tissue. Particular attention is given to singular value decomposition (SVD) methods, Bayesian approaches, and timing parameters, including time to maximum (Tmax), Delay, time to peak (TTP), and mean transit time (MTT). Differences in residue function estimation and threshold definition may generate variable outputs across software platforms, even from the same source dataset. Perfusion thresholds should therefore not be treated as universally interchangeable. CTP findings should be integrated with clinical status, non-contrast CT, CT angiography (CTA), collateral status, occlusion site, and imaging-to-treatment context, serving as decision-support tools rather than isolated measures of tissue viability.