Brain perfusion CT in acute stroke: current status

Dynamic perfusion CT has become a widely accepted imaging modality for the diagnostic workup of acute stroke patients. Although compared with standard spiral CT the use of multislice CT has broadened the range from which perfusion data may be derived in a single scan run. The advent of multidetector row technology has not really overcome the limited 3D capability of this technique. Multidetector CT angiography (CTA) of the cerebral arteries may in part compensate for this by providing additional information about the cerebrovascular status. This article describes the basics of cerebral contrast bolus scanning with a special focus on optimization of contrast/noise in order to ensure high quality perfusion maps. Dedicated scan protocols including low tube voltage (80 kV) as well as the use of highly concentrated contrast media are amongst the requirements to achieve optimum contrast signal from the short bolus passage through the brain. Advanced pre and postprocessing algorithms may help reduce the noise level, which may become critical in unconscious stroke victims. Two theoretical concepts have been described for the calculation of tissue perfusion from contrast bolus studies, both of which can be equally employed for brain perfusion imaging. For each perfusion model there are some profound limitations regarding the validity of perfusion values derived from ischemic brain areas. This makes the use of absolute quantitative cerebral blood flow (CBF) values for the discrimination of the infarct core from periinfarct ischemia questionable. Multiparameter imaging using maps of CBF, cerebral blood volume (CBV), and a time parameter of the local bolus transit enables analyzing of the cerebral perfusion status in detail. Perfusion CT exceeds plain CT in depicting cerebral hypoperfusion at its earliest stage yielding a sensitivity of about 90% for the detection of embolic and hemodynamic lesions within cerebral hemispheres. Qualitative assessment of brain perfusion can be further enhanced by adding relative perfusion indices from regions of interest. Multislice CTA using a collimation of 4 x 1 mm and high pitch factors allows for isotropic scanning of the brain supplying arteries from the aortic arch to the vertex in a single run. Various image processing modalities such as multiplanar reformations, curved planar reconstructions, maximum intensity projections, and volume rendering techniques are available to deal with the extensive data and to bring out those vascular lesions, which are of relevance for individual stroke. With the advent of multidetector CT advanced stroke protocols combining plain CT, perfusion CT and CTA can routinely be accomplished within a very short timespan thus ensuring the role of CT in the diagnostic workup of acute stroke.