Evaluation of Cerebral Ischemia with Brain Perfusion and the Intellispace Portal

George M. Ebert, MD, PhD, Associate Professor of Radiology, Chief, Informatics and Imaging Technology, Co-Director of Clinical MRI, University of Vermont College of Medicine, Burlington, VT, in affiliation with Fletcher Allen Healthcare

View content online at: http://www.appliedradiology.com/Issues/2011/12/Supplements/Evaluation-of-Cerebral-Ischemia-with-Brain-Perfusion-and-the-Intellispace-Portal.aspx

Abstract:  66-year-old male was seen at an outside hospital presenting with left hemiparesis and left-side neglect. At the outside hospital, the patient was administered tissue plasminogen activator (TPA) before transfer to our facility for possible intervention. Noncontrast computed tomography (CT), CT angiography (CTA), and perfusion CT images were acquired.

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Case Summary

A 66-year-old male was seen at an outside hospital presenting with left hemiparesis and left-side neglect. At the outside hospital, the patient was administered tissue plasminogen activator (TPA) before transfer to our facility for possible intervention. Noncontrast computed tomography (CT), CT angiography (CTA), and perfusion CT images were acquired.

Image Findings

There is a large area of infarct core seen in the posterior right middle cerebral artery (MCA) distribution, the right posterior cerebral artery (PCA) distribution and posterior right anterior cerebral artery (ACA) distribution. There is a smaller area of ischemia in the anterior right frontal lobe. (See Figures 1-4.)

Discussion

Accurate and efficient postprocessing with the CT Advanced Brain Perfusion and Advanced Vessel Analysis applications (IntelliSpace Portal, Philips Healthcare, Cleveland, OH, USA), allow for quick decisions to be made by the neurology team. The penumbra/infarct maps (summary maps) give the brain perfusion application an advantage in facilitating these expedient reviews.

We can use the summary maps to assess the likelihood of success with an intra-arterial intervention. Patients with a large infarct core and small amount of penumbra (brain at risk for infarction) are thought to have a lower success following intra-arterial intervention. On the other hand, in patients with a smaller infarct core and a larger amount of brain at risk, an argument can be made for intra-arterial intervention. In this case, due to the size of the infarct core, the number of occlusions (2 ACA and 2 MCA branches), and a relatively small area of brain at risk, it was elected to not proceed with intra-arterial therapy. In today’s climate, it was a difficult decision to not treat this patient; however, the advanced imaging made possible with the Philips iCT and the ease of postprocessing the brain perfusion and CTA data with the Philips IntelliSpace Portal made a hard decision easier.

Key Benefits

• Summary maps (penumbra/infarct maps), available in Philips’ CT Advanced Brain Perfusion application, support expedient decision making by the neurology team and offer an advantage.

• The iCT provides full brain coverage and allows for quantitative analysis when paired with the CT Advanced Brain Perfusion application.

Tables & Figures

  • Figure 1A. Figure 1. Images A, B, C, and D show an 80 mm brain perfusion study.
    Figure 1A.
  • Figure 1B.
    Figure 1B.
  • Figure 1C.
    Figure 1C.
  • Figure 1D.
    Figure 1D.
  • Figure 2. The middle and anterior cerebral artery ischemia are shown. Infarct and penumbra are both demonstrated here, although the ultimate treatment decision was based on the size of the infarct core relative to the size of the brain at risk and the significant risk of bleeding with thrombolytic therapy. The patient was observed and eventually a craniotomy was performed to relieve swelling and cerebral pressure.
    Figure 2.
  • Figure 3A. The arrows in images A and B show the inferior and superior occlusions of the MCA.
    Figure 3A.
  • Figure 3B.
    Figure 3B.
  • Figure 4. This 3D rendering is oriented so that the reader is looking from the back of the head. The left cerebral artery is intact. An occlusion is present in the right anterior cerebral artery and the A-2 branch of the RCA.
    Figure 4.