AdultBrainPerfusionCT PDF

Adult Brain Perfusion CT Protocols Version 2.
0 3/1/2016
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1
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Copyright © March 1, 2016 by AAPM. All rights reserved.
Adult Brain Perfusion CT Protocols Version 2.0 3/1/2016
ADULT BRAIN PERFUSION CT

Indications
Suspected acute infarction;
Assessment of reperfusion after treatment of acute stroke;
Vasculitis;
New neurological symptoms after subarachnoid hemorrhage suggesting vasospasm;
Evaluation of the hemodynamic significance of a carotid stenosis;
Transient ischemic attack;
Evaluation of the cerebral vascular reserve using acetazolamide challenge;
Evaluation of brain perfusion after significant head trauma;
Brain tumor.
Diagnostic Task
• Detect brain ischemia in stroke, transient ischemic attack, vasculitis;
• Distinguish already-infarcted brain from brain at risk of infarction;
• Identify regions of brain made ischemic by vasospasm;
• Detect altered brain perfusion downstream a significant carotid stenosis;
• Assess altered cerebral vascular reserve in patients with ischemic symptoms;
• Assess altered cerebral perfusion after traumatic brain injury;
• Identify early brain tumor recurrence and higher-grade tumor components.
Key Elements
• Time-resolved scans are used to track the flow of iodinated contrast media through the brain;
• Multiple images (20-40) are acquired over the same section of anatomy;
• Patients must be able to remain still during the exam in order to avoid motion misregistration;
• The table may remain stationary during the entire exam, or move back and forth between a few table
positions;
• Whole-brain perfusion CT can be accomplished using CT systems with wide detector arrays (8-16 cm);
alternatively, scan modes that move the patient back and forth over the desired scan volumes can be
used;
• Acquisitions are repeated at predetermined time intervals (e.g. every second to every 2-3 seconds) for
a predetermined duration (e.g. 40-90 seconds);
• Relatively thick image widths are used to minimize image noise (5-10 mm is common);
• Image quality is inferior to a routine head CT. That is, images are noisier and thicker.
• Data are used to generate color maps of hemodynamic significance:
--Blood volume (BV) and flow (BF), mean transit time (MTT), time to peak perfusion (TPP);
• A non-contrast-enhanced head CT and/or a CT angiogram may be combined with a perfusion CT scan.
Dose Management
• 80 kV should be used to increase iodine signal brightness;
• Low dose per single scan (i.e. one tube rotation) is critical, since repeated scanning will result in a
relatively high cumulative dose;
• Time interval between scans, and hence the total number of scans over the exam duration, should be
set carefully, taking into account the analysis algorithm (some approaches require relatively dense data
points);
• Dose (tube current) modulation should not be used, as it may interfere with the calculation of the BV
and BF parameters;
Additional Resources
• ACR Practice Guideline for the Performance of Computed Tomography (CT) Perfusion in
Neuroradiologic Imaging. (www.acr.org/Quality-Safety/Standards-Guidelines/Practice-Guidelines-by-
Modality/CT);
• AJNR Special Collection. Radiation Dose in Neuroradiology CT Protocols. Collection Editors: Max
Wintermark and Michael H. Lev (available at www.ajnr.org/specCol/specCollPCTToc.dtl).
2
BRAIN PERFUSION CT: Sample Images
Cerebral Blood Flow (CBF, in mL/100 g/min) Cerebral Blood Volume (CBV, in mL/100 g)
Mean Transit Time (MTT, in seconds) Peak Enhancement Curves
3
INDEX OF ADULT BRAIN PERFUSION CT PROTOCOLS (by manufacturer)
GE
Hitachi
Neurologica
Neusoft
Philips
Siemens
Toshiba
4
BRAIN PERFUSION CT (Selected GE Scanners)
GENERAL: This protocol may include an optional, non-contrast-enhanced head scan and/or an optional head CT angiogram.
Center the table height, such that the external auditory meatus is located at the center of the gantry and the landmarked
at the level of the canthomeatal line (S0). The patient’s chin should be tilted toward the chest (i.e. in a “tucked”
position) to minimize the amount of tilt needed to better avoid the eyes especially for modes that do not support tilt.
Perfusion protocols are for adults; modifications must be done for pediatrics.
CONTRAS T: Oral: None.

IV: 40 ml of 350 -370 mg/cc concentration contrast media at 4 ml/sec, followed by 25 ml saline flush at same rate.
Preferred injection site: 18–20 gauge IV in right antecubital vein or central line capable of a 4 ml/sec injection.
Optional second level can be examined after a 5 to 10 min delay.
S COUT: PA and Lateral, 200 mm coverage, 120 kV, 10 mA.
BRAIN PERFUS ION CT:

The radiologist will determine the scan range, referring to any previously acquired (optional) scanned series.
The injection rate and volume of contrast directly affects the duration of the scan. Consideration needs to be given to
these factors and patient cardiac output for appropriate scan delays and duration.
If a second location is desired, the start location of this group will be 1.5-2mm above the end of the first location.
Perfusion computations are performed on an image-processing workstation or scan console after scan completion.
Option 1: Axial mode (non-continuous axial acquisitions).

LightSpeed and LightSpeed and LightSpeed VCT and
GE
BrightSpeed 4/8 slice BrightSpeed 16 slice Discovery CT750 HD
Scan Type Axial Axial Axial
Rotation Time (s) 1 1 1
Detector Rows 16 16 64
Exam Duration (s) 44 44 44
Total Exposure Time (s) 22 22 22
kVp 80 80 80
Manual mA 150 150 150
AutomA/SmartmA OFF OFF OFF
SFOV Head Head Head
Prep Delay (s) 5 5 5
ISD (s) 1 1 1
DFOV (cm) 25 25 25
Image Thickness 5mm x 4i 5mm x 4i 5mm x 8i
Interval (mm) 0 0 0
Reconstruction
Standard Standard Standard
Algorithm
SS30-50
ASiR
(optional, if available)
Coverage (mm) 20 20 40
Temporal Sampling (s) 2 2 2
CTDI-vol (mGy) 200 @ 150 mA 220 @ 150 mA 216 @ 150 mA
Continued
5
BRAIN PERFUSION CT (Selected GE Scanners) (continued)
Option 2: Cine mode (continuous axial acquisition).

LightSpeed and LightSpeed and LightSpeed VCT and
GE
BrightSpeed 4/8 slice BrightSpeed 16 slice Discovery CT750 HD
Scan Type Cine Cine Cine
Rotation Time (s) 1 1 1
Detector Rows 16 16 64
Exam Duration (s) 45 45 45
Total Exposure Time (s) 45 45 45
kVp 80 80 80
Manual mA 150 150 150
Auto-mA/Smart -mA OFF OFF OFF
SFOV Head Head Head
Prep Delay (s) 5 5 5
DFOV (cm) 25 25 25
Image Thickness 5mm x 4i 5mm x 4i 5mm x 8i
Interval (mm) 0 0 0
Reconstruction Algorithm Standard Standard Standard
SS30-50
ASiR
Coverage (mm) 20 20 40
Time interval between
0.5 - 1 0.5 - 1 0.5 - 1
reconstructed images (s)
CTDI-vol (mGy) 407 @ 150 mA 452 @ 150 mA 441 @ 150 mA
Continued
6
BRAIN PERFUSION CT (Selected GE Scanners) (continued)
Option 3: Volume mode (table moves in and out of the gantry to increase coverage).
LightSpeed VCT and LightSpeed VCT and
GE
Discovery CT750 HD Discovery CT750 HD
Volume Shuttle Volume Shuttle
Scan Type
Axial Helical
Rotation Time (s) 0.4 0.4
Detector Rows 64 64
Total Exposure Time 13.6 sec 47.38 sec
Pitch N/A 0.984:1
Passes 17 28
kVp 80 80
Manual mA 400 200
AutomA/SmartmA OFF OFF
SFOV Head Head
Prep Group 5 5
ISD N/A N/A
DFOV 25 25
Image Thickness 5mm x 8i 5 mm
Interval (mm) 40 10
Reconstruction
Standard Standard
Algorithm
SS50
ASiR SS50 (ON)
Coverage (mm) 80 110-120
Temporal Sampling (s) 3 sec 3 sec
CTDI-vol (mGy) 178 @ 400 mA 261 @ 200 mA
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BRAIN PERFUSION CT (Selected HITACHI Scanners)
Scanogram: Lateral and PA: Scan from base of skull to vertex.
Dynamic scan (intermittent axial acquisitions at the same table location)
HITACHI Scenaria 64 slice

Scan Type Dynamic Scan
Rotation Time (s) 1
Detector Rows 64
Total Exposure Time (s) 20
kVp 80
mA 150
IntelliEC (AEC) OFF
Scan FOV (mm) 500
Sequence delay (s) 5 sec.
ISD (s) 1 sec.
DFOV (mm) 230
Image Thickness 5 mm x 8i
Interval (mm) 0
Filter 11
Intelli IP C
Coverage (mm) 40
CTDI-vol (mGy) 166
Images obtained using this Dynamic Scan protocol can be processed using TeraRecon iNtuition™ TDA clinical application to obtain
quantitative perfusion parameters.
Use of other manufacturer’s perfusion software applications may be appropriate, but the accuracy of the results has not been validated
by either Hitachi or the AAPM. Users should work with the software vendor to determine whether the data obtained with this scan
protocol are appropriate for the specific algorithm used to calculate perfusion parameters.
8
BRAIN PERFUSION CT (Selected NEUROLOGICA Scanners)
Scout: PA and Lateral, 200 mm coverage, 120kV at 3mA for both views.
NEUROLOGICA Ceretom BodyTom

Acquisition Mode 8 x 1.25 mm 8 x 1.25 mm
/collimation / 10mm / 10mm
Scan Voltage (kV) 100 100
Scan Current (mA) 6 6
Scan Time (s) 30-40 25
Rotation Time (s) 1 1
Slice Thickness (mm) 10 10
Increment / Table feed (mm) 0 0
Field of View (FOV) (cm) 25.3 30
Gantry Tilt (°) 0 0
Primary Reconstruction Kernel Soft Tissue Post Fossa / Vessel
Image Format DICOM DICOM
Contrast Agent Yes Yes
Dose (CTDIvol) (mGy) 328 408
Reference Scan Yes Yes
Views CBF, MTT, CBT and axial CBF, MTT, CBT and axial
Scan Coverage (mm) 10 10
Notes:
1. Scan voltage is limited to 100kV and cannot be changed by the CT technologist.
2. Maximum scan current is set to 6 mA.
3. Default scan time is 30 seconds. Lower mA setting is recommended for longer scans.
4. Low dose reference scan is available for scan localization prior to CTP scan.
9
BRAIN PERFUSION CT (Selected NEUSOFT Scanners)
GENERAL: Protocols are designed and intended for adult patients only. The gantry should be tilted to position the scan field
parallel to the Frankfort horizontal plane. Functional Imaging is used measure physiological processes in the brain.
Using a continuous or sequentially acquired dataset, at one anatomical position, the absorption of contrast material into
the brain tissue can be measured and quantified.

IV: 50m of 370 mg/cc of contrast media at 4-6 ml/sec followed by a 30 ml saline flush at 4ml/sec.
Preferred injection site: 18-20 gauge IV placed in right antecubital vein
S COUT (NV 16): Lateral and PA, Base of skull through vertex. 250 mm in length, 40 mA, 90 kVp
S COUT (NV 64): Lateral and PA, base of skull through vertex. 250 mm in length, 40 mA, 80 kVp

This scan is performed for a continuous 40 seconds.
The radiologist will determine the scan range, referring to any previously acquired (optional) scanned series.
After perfusion scan is complete, load perfusion images to the Brain Perfusion Application.
NEUSOFT NeuViz 64i/e NeuViz 16
Scan Type Axial Axial

Rotation Time
0.5 0.6
(s)
Collimation 32 x 0.625 16 x 1.5 mm
kVp 80 90
Reference
150 96
mAs
Pitch n/a n/a
DFOV (mm) 250 250
Resolution Standard Standard

Dose
OFF n/a
Modulation
ClearView 20%(optional) n/a
Cycle Time 1 sec 1.5 sec.

Scan
20 24
Coverage
Cycles 40 40
CTDIvol 260 249
RECON 1
Type Axial Axial
Filter F10 SA
Thickness
5 6
(mm)
Increment 5 6
(mm)
10
BRAIN PERFUSION CT (Selected PHILIPS Scanners)
GENERAL: These protocol parameters should not be used for pediatric patients.

IV: For Non-Jog scans: 40–50 mL contrast, followed by 20–40 mL saline
For Jog Mode scans: 70 mL contrast, followed by 45 mL saline
For all scans: Injection rate of 4–6 mL per second, 18–20 gauge IV placed in right antecubital vein
SURVIEW: Lateral, 120 kVp, 30 mA. From vertex to base of skull
Option 1: Non-Jog Mode.

Brilliance Brilliance Brilliance Brilliance
PHILIPS
16 slice 40/64 slice iCT SP iCT
Rotation Time (s) 0.5 0.5 0.4 0.4
Collimation 16 × 1.5 mm 32 × 1.25 mm 32 × 1.25 mm 64 × 1.25 mm
Coverage (mm) 24 40 40 80
kVp 90 80 80 80
mAs 125 125 100 100
ACS/DOM OFF OFF OFF OFF
Cycle Time (s) 2.0 2.0 1.5 1.5
Cycles 30 30 40 40
Thickness (mm) 6.0 5.0 5.0 5.0
Increment (mm) 0.0 0.0 0.0 0.0
Resolution Standard Standard Standard Standard
FOV (mm) 250 250 220 220
Filter UB UB UB UB
WC/WL 80/40 80/40 80/40 80/40
CTDI-vol (mGy) 240 132 160 148
Option 2: Jog Mode (Table moves back and forth between two positions).
Brilliance Brilliance Brilliance Brilliance
PHILIPS
16 slice 40/64 slice iCT SP iCT
Rotation Time (s) 0.5 0.5 0.4 0.4
Collimation 16 × 1.5 mm 32 × 1.25 mm 32 × 1.25 mm 64 × 1.25 mm
Coverage (mm) 48 80 80 160
kVp 90 80 80 80
mAs 125 125 100 100
ACS/DOM OFF OFF OFF OFF
Cycle Time (s)* 4 4 4 4
# of Jog Cycles 15 15 15 15
Thickness (mm) 6.0 5.0 5.0 5.0
Increment (mm) 0.0 0.0 0.0 0.0
Resolution Standard Standard Standard Standard
FOV (mm) 250 250 220 220
Filter UB UB UB UB
WC/WL 80/40 80/40 80/40 80/40
CTDI-vol (mGy) 120 66 80 72
* Cycle time represents the time from the start of one scan to the start of the next scan over the same piece of
anatomy (i.e., the sampling interval of the time attenuation curve). For the 4 s cycle time, the manufacturer’s
perfusion analysis software reports relative, rather than absolute, perfusion parameters. Absolute, quantitative
perfusion parameters are reported for cycle times less than or equal to 2.5 s.
11
BRAIN PERFUSION CT (Selected SIEMENS Scanners)
GENERAL: This protocol may include an optional, non-contrast-enhanced head scan and/or an optional head CT angiogram
Center the table height, such that the external auditory meatus is located at the center of the gantry.
The patient’s chin should be tilted toward the chest (i.e. in a “tucked” position).

IV: 35 to 50 mL of at least 300 mg/cc concentration injected with an iodine delivery rate of at least 1.75 g/s and an
injection time not longer than 8s followed by 20 to 30 mL of saline injected with the same flow rate.
An example fulfilling these restrictions would be: 35 ml contrast media (370mg/ml iodine, preheated to body
temperature), injection rate 5 ml/s followed by 20-30 ml saline with identical flow rate.
Preferred injection site: 18–20 gauge IV placed in right antecubital vein
TOPOGRAM: PA and Lateral, 512 mm coverage, 120 kV, 100 mA. Craniocaudal direction.

This scan is performed for a continuous 40 or 45 seconds.
The radiologist will determine the scan range, referring to any previously-acquired (optional) scanned series.
No Gantry Tilt for the periodic spiral (adapti ve 4D spiral).
Perspective 64
Emotion 16 S cope Power S ensation 64
S IEMENS Perspective 128
Scan M ode M ultiscan M ultiscan M ultiscan M ultiscan
Rotation Time (s) 1.0 1.0 1.0 1.0
Table M otion None None None None
Detector Configuration (mm) 6x3 16 x 1.2 32 x 1.2 24 x 1.2
Coverage per Rotation (mm) 18 19.2 38.4 28.8
Scan Range (mm) 18 19.2 38.4 28.8
Cycle Time (s) 3.75 3 3 1.0 (continuous)
Feed (mm/rot) - - - -
kV 80 80 80 80
mAs 150 150 150 200
Scan Field (mm) 200 200 200 200
Scan time (s) 40 40 40 40
CARE Dose4D OFF OFF OFF OFF
-
CARE kV - - -
CTDIvol (mGy) 394 394 391 297
RECON 1
Kernel H31s H31s H31s H31s
Slice (mm) 9.6 9.6 9.6 9.6
Increment (mm) 9.6 9.6 9.6 9.6
Perfusion computations are performed on an image-processing workstation after scan completion.
12
BRAIN PERFUSION CT (Selected SIEMENS Scanners) (Continued)
Definition Definition Edge Definition Flash Force

Definition AS 64
(Dual S ource) Definition AS + (Dual source 128-slice) (Dual source 192-slice)
S IEMENS
Scan M ode 4D Spiral 4D Spiral 4D Spiral 4D Spiral 4D Spiral
Rotation Time (s) 0.33 0.33 0.28 - 0.33 0.28 0.25
Table M otion Yes Yes Yes Yes Yes
Detector Configuration
24 x 1.2 16 x 1.2 32 x 1.2 32 x 1.2 48 x 1.2
(mm)
Coverage per Rotation 28.8 19.2 38.4 38.4 57.6
(mm)
Scan Range (mm) 62 84 86-100 100 114
Cycle Time (s) 1.5 1.5 1.5 1.5 1.5
Pitch variable variable variable variable variable
kV 80 80 80 80 70
Effective mAs 200 180 200 180 200
Scan Field (mm) 200 200 200 200 200
Scan time (s) 45 45 45 45 45
CARE Dose4D OFF OFF OFF OFF OFF
CARE kV OFF OFF OFF OFF OFF
CTDIvol (mGy) 220.0 281 211 - 222 235 148
RECON 1
Kernel H20f H20f H20f H20f Hr36
Slice (mm) 5.0 5.0 5.0 5.0 5.0
Increment (mm) 3.0 3.0 3.0 3.0 3.0
13
BRAIN PERFUSION CT (Selected TOSHIBA Scanners)
GENERAL: This protocol may include an optional, non-contrast-enhanced head scan and/or an optional head CT angiogram
Center the table height, such that the external auditory meatus is located at the center of the gantry.

IV: 50 mL of 370 mg/cc concentration contrast media @ 5-6 mL/sec followed by 50 mL saline at 5-6 mL/sec
Preferred injection site: 18–20 gauge IV placed in right antecubital vein.
S CANOGRAM: PA and Lateral, 240 mm coverage, 120 kV, 50 mA, caudal-cranial direction.

This scan is performed for 60 seconds. The radiologist will determine the scan range, referring to any previously-acquired
(optional) scanned series for the Aquilion Premium. For the Aquilion ONE, the entire head is covered.

*The image below shows the scan protocol for the Aquilion ONE. Each green bar represents a volume scan. The mA is increased for
the arterial portion of the scan to provide improved image quality for the digitally subtracted angiogram (DSA) image.
TOS HIBA Aquilion PRIME Aquilion Premium Aquilion ONE
Scan Type Dynamic Volume Continuous Dynamic Volume Intermittent Dynamic Volume Intermittent
Rotation Time (s) 1.5 0.75 0.75
Table M otion None None None
Detector Configuration 10 x 4 mm 160 x 0.5 mm 320 x 0.5 mm
Coverage per Rotation (mm) 40 80 160
Scan Range (mm) 40 80 160
Acquisition Interval (s)* Continuous 2 s initially, then 5 s 2 s initially, then 5 s
kV 80 80 80
310 (mask), 300 (arterial phase), 310 (mask), 300 (arterial phase),
mA 40
150 (elsewhere) 150 (elsewhere)
SURE
Exposure No No No
SFOV (mm) 240mm (S) 240mm (S) 240mm (S)
Delay after injection (s) 5 7 7
Scan Time (s) 49.5 53 53
CTDI-vol (mGy) 128.8 196.8 214.6
RECONS TRUCTION
Kernel 43 41 41
Thickness (mm) 10 0.5 0.5
Interval (mm) 10 0.5 0.5
DFOV (cm) 240 240 240
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Adult Brain Perfusion CT Protocols Version 2.

DISCLAIMER: TO THE EXTENT ALLOWED BY LOCAL LAW,

TO THE EXTENT ALLOWED BY LOCAL LAW, IN NO EVENT

ADULT BRAIN PERFUSION CT

Mean Transit Time (MTT, in seconds) Peak Enhancement Curves

INDEX OF ADULT BRAIN PERFUSION CT PROTOCOLS (by manufacturer)

CONTRAS T: Oral: None.

S COUT: PA and Lateral, 200 mm coverage, 120 kV, 10 mA.

BRAIN PERFUS ION CT:

Option 1: Axial mode (non-continuous axial acquisitions).

Option 2: Cine mode (continuous axial acquisition).

Scanogram: Lateral and PA: Scan from base of skull to vertex.

Dynamic scan (intermittent axial acquisitions at the same table location)

HITACHI Scenaria 64 slice

NEUROLOGICA Ceretom BodyTom

CONTRAS T: Oral: None.

BRAIN PERFUS ION CT:

NEUSOFT NeuViz 64i/e NeuViz 16

Scan Type Axial Axial

DFOV (mm) 250 250

Resolution Standard Standard

Cycle Time 1 sec 1.5 sec.

CTDIvol 260 249

CONTRAS T: Oral: None.

SURVIEW: Lateral, 120 kVp, 30 mA. From vertex to base of skull

Option 1: Non-Jog Mode.

CONTRAS T: Oral: None.

Preferred injection site: 18–20 gauge IV placed in right antecubital vein

BRAIN PERFUS ION CT:

Perfusion computations are performed on an image-processing workstation after scan completion.

Definition Definition Edge Definition Flash Force

Perfusion computations are performed on an image-processing workstation after scan completion.

CONTRAS T: Oral: None.

BRAIN PERFUS ION CT:

Perfusion computations are performed on an image-processing workstation after scan completion.

TOS HIBA Aquilion PRIME Aquilion Premium Aquilion ONE

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