Skip to main content
SpringerLink
Log in

An Appeal to Standardize CT- and MR-Perfusion

  • Review Article
  • Published:
Clinical Neuroradiology Aims and scope Submit manuscript

Abstract

Multiple treatment options and risk assessment in cerebrovascular diseases are the actual challenges in diagnostic as well as in interventional neuroradiology.

Acute ischemic stroke essentially requires rapid detection of the location and extent of infarction and tissue at risk for making treatment decisions. In the acute setting, modern multiparametric perfusion imaging protocols help to determine infarct core and adjacent penumbral tissue, and they enable the estimation of collateral flow of intra- and extracranial arteries. In subacute delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) or chronic occlusive neurovascular diseases estimation of residual and collateral flow may be even more difficult.

Prediction of sufficient or insufficient supply of brain tissue may be essential to balance conservative against interventional therapies. However, so far no established reliable thresholds are available for determining tissue at acute, subacute, chronic progressive, or chronic risk.

Reliable and reproducible thresholds require quantitative perfusion measurements with a calibrated instrument. But the measurement instrument is not at all defined-a variety of parameter settings, different algorithms based on multiple assumptions and a wide variety of published normal and pathologic values for perfusion parameters indicate the problem. In the following text, we explain how deep the problem may be enrooted within techniques and algorithms impeding broad use of perfusion for many clinical issues.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Greitz T. A radiologic study of the brain circulation by rapid serial angiography of the carotid artery. Acta Radiol Suppl. 1956;140:1–123.

    PubMed  Google Scholar 

  2. Heiss WD. Ischemic penumbra: evidence from functional imaging in man. J Cereb Blood Flow Metab. 2000;20:1276–93.

    Article  CAS  PubMed  Google Scholar 

  3. Mies G, Ishimaru S, Xie Y, Seo K, Hossmann KA. Ischemic thresholds of cerebral protein synthesis and energy state following middle cerebral artery occlusion in rat. J Cereb Blood Flow Metab. 1991;11:753–61.

    Article  CAS  PubMed  Google Scholar 

  4. Astrup J, Siesjo BK, Symon L. Thresholds in cerebral ischemia—the ischemic penumbra. Stroke. 1981;12:723–5.

    Article  CAS  PubMed  Google Scholar 

  5. Axel L. Cerebral blood flow determination by rapid-sequence computed tomography. Radiology. 1980;137:679–86.

    Article  CAS  PubMed  Google Scholar 

  6. Klotz E, König M. Perfusion measurements of the brain: using dynamic CT for the quantitative assessment of cerebral ischemia in acute stroke. Eur J Radiol. 1999;30:170–84.

    Article  CAS  PubMed  Google Scholar 

  7. Wintermark M, Thiran JP, Maeder P, Schnyder P, Meuli R. Simultaneous measurement of regional cerebral blood flow by perfusion CT and stable xenon CT: a validation study. AJNR Am J Neuroradiol. 2001;22:905–14.

    CAS  PubMed  Google Scholar 

  8. Meier P, Zierler KL. On the theory of the indicator-dilution method for measurement of blood flow and volume. J Appl Physiol. 1954;6:731–44.

    CAS  PubMed  Google Scholar 

  9. Morhard D, Wirth CD, Fesl G, Schmidt C, Reiser MF, Becker CR, Ertl-Wagner B. Advantages of extended brain perfusion computed tomography: 9.6 cm coverage with time resolved computed tomography-angiography in comparison to standard stroke-computed tomography. Invest Radiol. 2010;45:363–9.

  10. Page M, Nandurkar D, Crossett MP, Stuckey SL, Lau KP, Kenning N, Troupis JM. Comparison of 4 cm Z-axis and 16 cm Z-axis multidetector CT-Perfusion. Eur Radiol. 2010;20:1508–14.

  11. Frölich AM, Psychogios MN, Klotz E, Schramm R, Knauth M, Schramm P. Angiographic reconstructions from whole-brain perfusion CT for the detection of large vessel occlusion in acute stroke. Stroke. 2012;43:97–102.

    Article  PubMed  Google Scholar 

  12. Frölich AM, Schrader D, Klotz E, Schramm R, Wasser K, Knauth M, Schramm P. 4D CT angiography more closely defines intracranial thrombus burden than single-phase CT angiography. AJNR Am J Neuroradiol. 2013;34:1908–13.

    Article  PubMed  Google Scholar 

  13. Frölich AM, Wolff SL, Psychogios MN, Klotz E, Schramm R, Wasser K, Knauth M, Schramm P. Time-resolved assessment of collateral flow using 4D CT angiography in large-vessel occlusion stroke. Eur Radiol. 2014;24:390–6.

    Article  PubMed  Google Scholar 

  14. Kaschka IN, Kloska SP, Struffert T, Engelhorn T, Gölitz P, Kurka N, Köhrmann M, Schwab S, Doerfler A. Clot burden and collaterals in anterior circulation stroke: Differences between single-phase CTA and multi-phase 4D-CTA. Clin Neuroradiol. 2014 Nov 20. [Epub ahead of print]

  15. Psychogios MN, Schramm P, Frölich AM, Kallenberg K, Wasser K, Reinhardt L, Kreusch AS, Jung K, Knauth M. Alberta Stroke Program Early CT Scale evaluation of multimodal computed tomography in predicting clinical outcomes of stroke patients treated with aspiration thrombectomy. Stroke. 2013;44:2188–93.

    Article  PubMed  Google Scholar 

  16. Turowski B, Haenggi D, Wittsack HJ, Beck A, Aurich V. [Computerized analysis of brain perfusion parameter images]. Rofo. 2007;179:525–9.

  17. Mathys C, Martens D, Reichelt DC, Caspers J, Aissa J, May R, Hänggi D, Antoch G, Turowski B. Long-term impact of perfusion CT data after subarachnoid hemorrhage. Neuroradiology. 2013;55:1323–31.

    Article  PubMed  Google Scholar 

  18. Caspers J, Rubbert C, Turowski B, Martens D, Reichelt DC, May R, Aissa J, Hänggi D, Etminan N, Mathys C. Timing of mean transit time maximization is associated with neurological outcome after subarachnoid hemorrhage. Clin Neuroradiol. 2015 May 5. [Epub ahead of print]

  19. Dolatowski K, Malinova V, Frölich AM, Schramm R, Haberland U, Klotz E, Mielke D, Knauth M, Schramm P. Volume perfusion CT (VPCT) for the differential diagnosis of patients with suspected cerebral vasospasm: qualitative and quantitative analysis of 3D parameter maps. Eur J Radiol. 2014;83:1881–9.

    Article  CAS  PubMed  Google Scholar 

  20. Schramm P, Schellinger PD, Klotz E, Kallenberg K, Fiebach JB, Külkens S, Heiland S, Knauth M, Sartor K. Comparison of perfusion computed tomography and computed tomography angiography source images with perfusion weighted imaging and diffusion weighted imaging in patients with acute stroke of less than 6 hours duration. Stroke. 2004;35:1652–8.

    Article  PubMed  Google Scholar 

  21. Wintermark M, Rowley HA, Lev MH. Acute stroke triage to intravenous thrombolysis and other therapies with advanced CT or MR imaging: pro CT. Radiology. 2009;251:619–26.

    Article  PubMed  Google Scholar 

  22. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, Schonewille WJ, Vos JA, Nederkoorn PJ, Wermer MJ, van Walderveen MA, Staals J, Hofmeijer J, van Oostayen JA, Lycklama à Nijeholt GJ, Boiten J, Brouwer PA, Emmer BJ, de Bruijn SF, van Dijk LC, Kappelle LJ, Lo RH, van Dijk EJ, de Vries J, de Kort PL, van Rooij WJ, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Visser MC, Bot JC, Vroomen PC, Eshghi O, Schreuder TH, Heijboer RJ, Keizer K, Tielbeek AV, den Hertog HM, Gerrits DG, van den Berg-Vos RM, Karas GB, Steyerberg EW, Flach HZ, Marquering HA, Sprengers ME, Jenniskens SF, Beenen LF, van den Berg R, Koudstaal PJ, van Zwam WH, Roos YB, van der Lugt A, van Oostenbrugge RJ, Majoie CB, Dippel DW; MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372:11–20.

    Article  PubMed  Google Scholar 

  23. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn SI, Swartz RH, Barber PA, Coutts SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD; ESCAPE Trial Investigators Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372:1019–30.

    Article  CAS  PubMed  Google Scholar 

  24. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, Yan B, Dowling RJ, Parsons MW, Oxley TJ, Wu TY, Brooks M, Simpson MA, Miteff F, Levi CR, Krause M, Harrington TJ, Faulder KC, Steinfort BS, Priglinger M, Ang T, Scroop R, Barber PA, McGuinness B, Wijeratne T, Phan TG, Chong W, Chandra RV, Bladin CF, Badve M, Rice H, de Villiers L, Ma H, Desmond PM, Donnan GA, Davis SM; EXTEND-IA Investigators. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372:1009–18.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Diagnostic and Interventional Radiology, University Dusseldorf, 40225, Dusseldorf, Germany

    B. Turowski

  2. Universität zu Lübeck, Institut für Neuroradiologie UKSH Universitätsklinikum Schleswig-Holstein Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland

    P. Schramm

Authors
  1. B. Turowski
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. P. Schramm
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to B. Turowski.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Turowski, B., Schramm, P. An Appeal to Standardize CT- and MR-Perfusion. Clin Neuroradiol 25 (Suppl 2), 205–210 (2015). https://doi.org/10.1007/s00062-015-0444-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00062-015-0444-5

Keywords

Search

Navigation