BACKGROUND AND PURPOSE: Perfusion imaging sequences are an important part of imaging studies designed to provide information to guide therapy for treatment of cerebrovascular disease. The purpose of this study was to perform a meta-analysis of the medical literature on perfusion imaging to determine its role in clinical decision making for patients with acute cerebral ischemia. MATERIALS AND METHODS: We searched MEDLINE by using a strategy that combined terms related to perfusion imaging with terms related to acute cerebral ischemia and brain tumors. We identified 658 perfusion imaging articles and classified them according to the clinical usefulness criteria of Thornbury and Fryback. We found 59 articles with promise of indicating usefulness in clinical decision making. We devised and implemented a clinical decision making scoring scale more appropriate to the topic of acute cerebral ischemia. RESULTS: Several articles provided important insights into the physiologic processes underlying acute cerebral ischemia by correlation of initial perfusion imaging deficits with clinical outcome or ultimate size of the infarct. However, most articles showed relatively low relevance to influencing decisions in implementing treatment. CONCLUSION: Most perfusion imaging articles are oriented toward important topics such as optimization of imaging parameters, determination of ischemia penumbra, and prediction of outcome. However, information as to the role of perfusion imaging in clinical decision making is lacking. Studies are needed to demonstrate that use of perfusion imaging changes outcome of patients with acute cerebral ischemia.