Clinical application of perfusion computed tomography in neurosurgery

Clinical article

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  • 1 Division of Neurosurgery,
  • 2 Department of Surgery, National Taiwan University Hospital, Taipei;
  • 3 Center for Optoelectronic Biomedicine, National Taiwan University College of Medicine, Taipei;
  • 4 Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Yun-Lin branch, Yun-Linp;
  • 5 Department of Neurosurgery, Chang-Hau Christian Hospital, Chang-Ha;
  • 6 Department of Neurosurgery, China Medical University, Bei-Gang Hospital, Yun-Lin, Taiwan; and
  • 7 Neuroradiology Division, Department of Radiology, University of Virginia, Charlottesville, Virginia
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Object

Currently, perfusion CT (PCT) is a valuable imaging technique that has been successfully applied to the clinical management of patients with ischemic stroke and aneurysmal subarachnoid hemorrhage (SAH). However, recent literature and the authors' experience have shown that PCT has many more important clinical applications in a variety of neurosurgical conditions. Therefore, the authors share their experiences of its application in various diseases of the cerebrovascular, neurotraumatology, and neurooncology fields and review the pertinent literature regarding expanding PCT applications for neurosurgical conditions, including pitfalls and future developments.

Methods

A pertinent literature search was conducted of English-language articles describing original research, case series, and case reports from 1990 to 2011 involving PCT and with relevance and applicability to neurosurgical disorders.

Results

In the cerebrovascular field, PCT is already in use as a diagnostic tool for patients suspected of having an ischemic stroke. Perfusion CT can be used to identify and define the extent of the infarct core and ischemic penumbra core, and thus aid patient selection for acute reperfusion therapy. For patients with aneurysmal SAH, PCT provides assessment of early brain injury, cerebral ischemia, and infarction, in addition to vasospasm. It may also be used to aid case selection for aggressive treatment of patients with poor SAH grade. In terms of oncological applications, PCT can be used as an imaging biomarker to assess angiogenesis and response to antiangiogenetic treatments, differentiate between glioma grades, and distinguish recurrent tumor from radiation necrosis. In the setting of traumatic brain injury, PCT can detect and delineate contusions at an early stage. In patients with mild head injury, PCT results have been shown to correlate with the severity and duration of postconcussion syndrome. In patients with moderate or severe head injury, PCT results have been shown to correlate with patients' functional outcome.

Conclusions

Perfusion CT provides quantitative and qualitative data that can add diagnostic and prognostic value in a number of neurosurgical disorders, and also help with clinical decision making. With emerging new technical developments in PCT, such as characterization of blood-brain barrier permeability and whole-brain PCT, this technique is expected to provide more and more insight into the pathophysiology of many neurosurgical conditions.

Abbreviations used in this paper:BBB = blood-brain barrier; CBF = cerebral blood flow; CBV = cerebral blood volume; CPP = cerebral perfusion pressure; CTA = CT angiography; CVR = cerebrovascular reserve; DWI = diffusion-weighted imaging; GCS = Glasgow Coma Scale; GOSE = Glasgow Outcome Scale extended; ICA = internal carotid artery; ICH = intracranial hemorrhage; ICP = intracranial pressure; MCA = middle cerebral artery; MTT = mean transit time; PCT = perfusion CT; SAH = subarachnoid hemorrhage; TBI = traumatic brain injury; TIA = transient ischemic attack.

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Contributor Notes

Address correspondence to: Max Wintermark, M.D., M.A.S., Neuroradiology Division, Department of Radiology, University of Virginia Medical Center, 1215 Lee St.–New Hospital, P.O. Box 800170, Charlottesville, VA 22908. email: max.wintermark@virginia.edu.

Drs. Huang and Tsai contributed equally to this work.

Please include this information when citing this paper: published online November 22, 2013; DOI: 10.3171/2013.10.JNS13103.

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