The Role of Comprehensive Brain Perfusion and Whole-Body CT Using Split-Bolus Injection in Diagnosing Multiple Thromboembolism in a Wake-Up Stroke Patient: A Case Report.

Brain computed tomography (CT) perfusion imaging is essential for determining patient eligibility for mechanical thrombectomy in wake-up stroke cases. CT scanning is also valuable for enabling simultaneous whole-body imaging, which supports access route evaluation and helps exclude differential diagnoses such as aortic dissection. In this report, we describe comprehensive brain perfusion CT and whole-body imaging for diagnostic evaluation in a 91-year-old female patient who presented to the emergency department with a suspected wake-up stroke. The use of the split-bolus contrast injection method, combined with a low tube voltage, enabled a simplified protocol that used a minimal contrast medium dose, achieving CT attenuation values of ≥400 Hounsfield units throughout the major thoracoabdominal vessels. This enhanced vascular visualization supported a prompt and accurate diagnosis. We identified an exceptionally rare case of multiple simultaneous thromboembolisms, including cerebral infarction due to brachiocephalic artery occlusion, pulmonary thromboembolism, left atrial thrombus, and myocardial infarction. All diagnoses were made in a single imaging session. Although rare, concurrent aortic dissection and myocardial infarction have been reported in patients with acute ischemic stroke, underscoring the clinical importance of comprehensive diagnostic evaluation. This case illustrates the utility of integrated brain perfusion and whole-body CT scanning in identifying multi-site thromboembolisms.