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The hemodynamic changes of acute small subcortical infarction (SSI) are not well understood. We evaluate the hemodynamic changes and collaterals in acute SSI using perfusion magnetic resonance imaging (MRI). A total of 103 patients with acute SSI in penetrating artery territories were recruited and underwent MRI within 24 h of stroke onset. Using 4D dynamic perfusion MRI, they were divided into three patterns: 25 (24%) with normal perfusion, 31 (30%) with compensated perfusion, and 47 (46%) with hypoperfusion. The development of anterograde or retrograde collaterals was also evaluated. Patients with hypoperfusion pattern had the highest rate of early neurological deterioration (32%,  p  = 0.007), the largest initial and final infarction volumes ( p  &lt; 0.001 and  p  = 0.029), the lowest relative cerebral blood flow (0.63,  p  &lt; 0.001), and the lowest rate of anterograde and retrograde collaterals (19%,  p  &lt; 0.001; 66%,  p  = 0.002). The anterograde collaterals were associated with higher relative cerebral blood volume (0.91 vs. 0.77;  p  = 0.024) and a higher rate of deep cerebral microbleeds (48 vs. 21%;  p  = 0.028), whereas retrograde collaterals were associated with higher systolic and diastolic blood pressure ( p  = 0.031 and 0.020), smaller initial infarction volume (0.81 vs. 1.34 ml,  p  = 0.031), and a higher rate of lobar cerebral microbleeds (30 vs. 0%;  p  = 0.013). Both anterograde and retrograde collaterals may play a critical role in maintaining cerebral perfusion and can have an impact on patient clinical outcomes. Further studies are warranted to verify these findings and to investigate effective treatments.

Perfusion Defects and Collateral Flow Patterns in Acute Small Subcortical Infarction: a 4D Dynamic MRI Study