Skip to main content
SpringerLink
Log in

Order of CT stroke protocol (CTA before or after CTP): impact on image quality

  • Diagnostic Neuroradiology
  • Published:
Neuroradiology Aims and scope Submit manuscript

Abstract

Introduction

The purpose of this study was to determine the appropriate order of CT angiography and CT perfusion in a multimodal stroke CT protocol.

Methods

Forty patients with clinical suspicion of an acute cerebral infarct underwent non-enhanced CT (NECT), CT angiography (CTA), and CT perfusion (CTP). Twenty examinations were performed with CTP before CTA (group 1) and 20 in reversed order (group 2). Mean densities were determined at baseline and peak enhancement of CTP, as well as on source images of CTA in defined brain regions. Contrast of extra-/intracranial arteries and veins was rated according to a 5-point scale (1 = excellent, 5 = poor). CT-perfusion maps were assessed by determining the mean transit time (MTT), cerebral blood flow (CBF), and blood volume (CBV) in identical regions.

Results

Mean densities between both groups were not significantly different for CTA and CTP at peak enhancement. At CTP baseline, mean densities between groups 1 and 2 were different for all points except for GM and WM. There was no significant difference between both groups for the mean delta (the difference between baseline and peak enhancement), as well as for mean MTT, CBV, and CBF. Subjective evaluation of the CTA quality revealed no difference between both protocols, except for the extracranial venous contrast, which was less severe in group 2.

Conclusion

Reversal of CT stroke protocol had no significant influence on quantitative parameters of CTP. Subjective quality of extracranial venous contrast was rated to be superior when CTA was performed before CTP.

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

Similar content being viewed by others

References

  1. Donnan G, Fisher M, Macleod M, Davis S (2008) Stroke. Lancet 371:1612–1623

    Article  PubMed  CAS  Google Scholar 

  2. The world health report 2004. Annex table 2: Deaths by cause, sex and mortality stratum in who regions, estimates for 2002. Geneva World Health Organization, 2004.

  3. del Zoppo G, Higashida R, Furlan A, Pessin M, Rowley H, Gent M (1998) PROACT: a phase II randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke. PROACT investigators. Prolyse in acute cerebral thromboembolism. Stroke 29:4–11

    Article  PubMed  Google Scholar 

  4. Smith W, Sung G, Saver J, Budzik R, Duckwiler G, Liebeskind D, Lutsep H, Rymer M, Higashida R, Starkman S, Gobin Y, Frei D, Grobelny T, Hellinger F, Huddle D, Kidwell C, Koroshetz W, Marks M, Nesbit G, Silverman I, Investigators MM (2008) Mechanical thrombectomy for acute ischemic stroke: final results of the multi MERCI trial. Stroke 39:1205–1212

    Article  PubMed  Google Scholar 

  5. Smith W, Sung G, Starkman S, Saver J, Kidwell C, Gobin Y, Lutsep H, Nesbit G, Grobelny T, Rymer M, Silverman I, Higashida R, Budzik R, Marks M, Investigators MT (2005) Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the merci trial. Stroke 36:1432–1438

    Article  PubMed  Google Scholar 

  6. Kulcsár Z, Bonvin C, Lovblad K, Gory B, Yilmaz H, Sztajzel R, Rufenacht D (2010) Use of the enterprise intracranial stent for revascularization of large vessel occlusions in acute stroke. Klin Neuroradiol Feb 28 (in press)

  7. Lövblad K, Baird A (2010) Computed tomography in acute ischemic stroke. Neuroradiology 52:175–187

    Article  PubMed  Google Scholar 

  8. Latchaw RE, Alberts MJ, Lev MH, Connors JJ, Harbaugh RE, Higashida RT, Hobson R, Kidwell CS, Koroshetz WJ, Mathews V, Villablanca P, Warach S, Walters B (2009) American Heart Association Council on Cardiovascular Radiology and Intervention SrC, and the Interdisciplinary Council on Peripheral Vascular Disease: Recommendations for imaging of acute ischemic stroke: a scientific statement from the American Heart Association. Stroke 40:3646–3678

    Article  PubMed  Google Scholar 

  9. Klingebiel R, Bohner G, Zimmer C, Rogalla P, Masuhr F, Lehmann R (2002) Using multislice spiral CT in neuroradiologic imaging. Nervenarzt 73:729–735

    Article  PubMed  CAS  Google Scholar 

  10. Mayer T, Hamann G, Baranczyk J, Rosengarten B, Klotz E, Wiesmann M, Missler U, Schulte-Altedorneburg G, Brueckmann H (2000) Dynamic CT perfusion imaging of acute stroke. AJNR Am J Neuroradiol 21:1441–1449

    PubMed  CAS  Google Scholar 

  11. Wintermark M (2005) Brain perfusion-CT in acute stroke patients. Eur Radiol 15(Suppl 4):D28–D31

    PubMed  Google Scholar 

  12. Konstas A, Goldmakher G, Lee T, Lev M (2009) Theoretic basis and technical implementations of CT perfusion in acute ischemic stroke, part 1: theoretic basis. AJNR Am J Neuroradiol 30:662–668

    Article  PubMed  CAS  Google Scholar 

  13. Soares B, Dankbaar J, Bredno J, Cheng S, Bhogal S, Dillon W, Wintermark M (2009) Automated versus manual post-processing of perfusion-ct data in patients with acute cerebral ischemia: influence on interobserver variability. Neuroradiology 51:445–451

    Article  PubMed  Google Scholar 

  14. Lee I, You J, Lee J, Whang K, Kim M, Kim Y, Lee M, Group BR (2010) Accuracy of the detection of infratentorial stroke lesions using perfusion CT: an experimenter-blinded study. Neuroradiology 52(12):1095–1100

    Article  PubMed  Google Scholar 

  15. Eckert B, Küsel T, Leppien A, Michels P, Müller-Jensen A, Fiehler J (2010) Clinical outcome and imaging follow-up in acute stroke patients with normal perfusion ct and normal ct angiography. Neuroradiology Apr 27 (in press)

  16. Bektas H, Wu TC, Kasam M, Harun N, Sitton CW, Grotta JC, Savitz SI (2010) Increased blood–brain barrier permeability on perfusion ct might predict malignant middle cerebral artery infarction. Stroke 41:2539–2544

    Article  PubMed  Google Scholar 

  17. Hopyan J, Ciarallo A, Dowlatshahi D, Howard P, John V, Yeung R, Zhang L, Kim J, MacFarlane G, Lee TY, Aviv RI (2010) Certainty of stroke diagnosis: incremental benefit with ct perfusion over noncontrast CT and CT angiography. Radiology 255:142–153

    Article  PubMed  Google Scholar 

  18. de Lucas E, Sánchez E, Gutiérrez A, Mandly A, Ruiz E, Flórez A, Izquierdo J, Arnáiz J, Piedra T, Valle N, Bañales I, Quintana F (2008) Ct protocol for acute stroke: tips and tricks for general radiologists. Radiographics 28:1673–1687

    Article  PubMed  Google Scholar 

  19. Murphy B, Fox A, Lee D, Sahlas D, Black S, Hogan M, Coutts S, Demchuk A, Goyal M, Aviv R, Symons S, Gulka I, Beletsky V, Pelz D, Chan R, Lee T (2008) White matter thresholds for ischemic penumbra and infarct core in patients with acute stroke: CT perfusion study. Radiology 247:818–825

    Article  PubMed  Google Scholar 

  20. Wintermark M, Sincic R, Sridhar D, Chien J (2008) Cerebral perfusion CT: technique and clinical applications. J Neuroradiol 35:253–260

    Article  PubMed  CAS  Google Scholar 

  21. Dittrich R, Kloska S, Fischer T, Nam E, Ritter M, Seidensticker P, Heindel W, Nabavi D, Ringelstein E (2008) Accuracy of perfusion-CT in predicting malignant middle cerebral artery brain infarction. J Neurol 255:896–902

    Article  PubMed  CAS  Google Scholar 

  22. Ryu C, Lee D, Kim H, Lee J, Choi C, Kim S, Suh D (2006) Acquisition of MR perfusion images and contrast-enhanced MR angiography in acute ischaemic stroke patients: which procedure should be done first? Br J Radiol 79:962–967

    Article  PubMed  CAS  Google Scholar 

  23. Sourbron S (2010) Technical aspects of MR perfusion. Eur J Radiol 276:304–313

    Article  Google Scholar 

  24. Bokkers RP, van der Worp HB, Mali WP, Hendrikse J (2009) Noninvasive mr imaging of cerebral perfusion in patients with a carotid artery stenosis. Neurology 73:869–875

    Article  PubMed  CAS  Google Scholar 

  25. Bokkers RP, van Osch MJ, van der Worp HB, de Borst GJ, Mali WP, Hendrikse J (2010) Symptomatic carotid artery stenosis: impairment of cerebral autoregulation measured at the brain tissue level with arterial spin-labeling MR imaging. Radiology 256:201–208

    Article  PubMed  Google Scholar 

  26. Quarles C, Ward B, Schmainda K (2005) Improving the reliability of obtaining tumor hemodynamic parameters in the presence of contrast agent extravasation. Magn Reson Med 53:1307–1316

    Article  PubMed  CAS  Google Scholar 

  27. Schmainda K, Rand S, Joseph A, Lund R, Ward B, Pathak A, Ulmer J, Badruddoja M, Baddrudoja M, Krouwer H (2004) Characterization of a first-pass gradient-echo spin-echo method to predict brain tumor grade and angiogenesis. AJNR Am J Neuroradiol 25:1524–1532

    PubMed  Google Scholar 

  28. Edelman R, Mattle H, Atkinson D, Hill T, Finn J, Mayman C, Ronthal M, Hoogewoud H, Kleefield J (1990) Cerebral blood flow: assessment with dynamic contrast-enhanced t2*-weighted MR imaging at 1.5 t. Radiology 176:211–220

    PubMed  CAS  Google Scholar 

  29. Camargo EC, Furie KL, Singhal AB, Roccatagliata L, Cunnane ME, Halpern EF, Harris GJ, Smith WS, Gonzalez RG, Koroshetz WJ, Lev MH (2007) Acute brain infarct: detection and delineation with ct angiographic source images versus nonenhanced CT scans. Radiology 244:541–548

    Article  PubMed  Google Scholar 

  30. Coutts SB, Lev MH, Eliasziw M, Roccatagliata L, Hill MD, Schwamm LH, Pexman JH, Koroshetz WJ, Hudon ME, Buchan AM, Gonzalez RG, Demchuk AM (2004) Aspects on CTA source images versus unenhanced CT: added value in predicting final infarct extent and clinical outcome. Stroke 35:2472–2476

    Article  PubMed  Google Scholar 

  31. Lin K, Rapalino O, Law M, Babb JS, Siller KA, Pramanik BK (2008) Accuracy of the Alberta Stroke Program early CT score during the first 3 hours of middle cerebral artery stroke: comparison of noncontrast CT, CT angiography source images, and CT perfusion. AJNR Am J Neuroradiol 29:931–936

    Article  PubMed  CAS  Google Scholar 

  32. Lev MH, Segal AZ, Farkas J, Hossain ST, Putman C, Hunter GJ, Budzik R, Harris GJ, Buonanno FS, Ezzeddine MA, Chang Y, Koroshetz WJ, Gonzalez RG, Schwamm LH (2001) Utility of perfusion-weighted CT imaging in acute middle cerebral artery stroke treated with intra-arterial thrombolysis: prediction of final infarct volume and clinical outcome. Stroke 32:2021–2028

    Article  PubMed  CAS  Google Scholar 

  33. Sharma M, Fox AJ, Symons S, Jairath A, Aviv RI (2010) CT angiographic source images: flow- or volume-weighted? AJNR Am J Neuroradiol Nov 24 (in press)

Download references

Conflict of interest

We declare that we have no conflict of interest.

Author information

Authors and Affiliations

  1. Department of Radiology, Klinikum rechts der Isar, Technical University, Munich, Germany

    Franziska Dorn, Daniela Muenzel, Reinhard Meier, Ernst J. Rummeny & Armin Huber

  2. Department of Radiology and Neuroradiology, University Hospital of Cologne, Cologne, Germany

    Franziska Dorn

  3. Department of Radiology and Neuroradiology, University Hospital of Cologne, Cologne, Germany

    Thomas Liebig

  4. Department of Neurology, Klinikum rechts der Isar, Technical University, Munich, Germany

    Holger Poppert

  5. Institut für Radiologie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, Munich, Germany

    Franziska Dorn

Authors
  1. Franziska Dorn
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Thomas Liebig
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Daniela Muenzel
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Reinhard Meier
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Holger Poppert
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ernst J. Rummeny
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Armin Huber
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Franziska Dorn.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Dorn, F., Liebig, T., Muenzel, D. et al. Order of CT stroke protocol (CTA before or after CTP): impact on image quality. Neuroradiology 54, 105–112 (2012). https://doi.org/10.1007/s00234-011-0840-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00234-011-0840-8

Keywords

Search

Navigation