Perfusion scanning

Perfusion is the passage of fluid through the lymphatic system or blood vessels to an organ or a tissue. The practice of perfusion scanning, is the process by which this perfusion can be observed, recorded and quantified. The term perfusion scanning encompasses a wide range of medical imaging modalities. Perfusion is the passage of fluid through the lymphatic system or blood vessels to an organ or a tissue. The practice of perfusion scanning, is the process by which this perfusion can be observed, recorded and quantified. The term perfusion scanning encompasses a wide range of medical imaging modalities. With the ability to ascertain data on the blood flow to vital organs such as the heart and the brain, doctors are able to make quicker and more accurate choices on treatment for patients. Nuclear medicine has been leading perfusion scanning for some time, although the modality has certain pitfalls. It is often dubbed 'unclear medicine' as the scans produced may appear to the untrained eye as just fluffy and irregular patterns. More recent developments in CT and MRI have meant clearer images and solid data, such as graphs depicting blood flow, and blood volume charted over a fixed period of time. Using radioactive microspheres is an older method of measuring perfusion than the more recent imaging techniques. This process involves labeling microspheres with radioactive isotopes and injecting these into the test subject. Perfusion measurements are taken by comparing the radioactivity of selected regions within the body to radioactivity of blood samples withdrawn at the time of microsphere injection. Later, techniques were developed to substitute radioactively labeled microspheres for fluorescent microspheres. The method by which perfusion to an organ measured by CT is still a relatively new concept, although the original framework and principles were concretely laid out as early as 1980 by Leon Axel at University of California San Francisco. It is most commonly carried out for neuroimaging using dynamic sequential scanning of a pre-selected region of the brain during the injection of a bolus of iodinated contrast material as it travels through the vasculature. Various mathematical models can then be used to process the raw temporal data to ascertain quantitative information such as rate of cerebral blood flow (CBF) following an ischemic stroke or aneurysmal subarachnoid hemorrhage. Practical CT perfusion as performed on modern CT scanners was first described by Ken Miles, Mike Hayball and Adrian Dixon from Cambridge UK and subsequently developed by many individuals including Matthias Koenig and Ernst Klotz in Germany, and later by Max Wintermark in Switzerland and Ting-Yim Lee in Ontario, Canada. There are different techniques of Perfusion MRI, the most common being dynamic contrast-enhanced (DCE), dynamic susceptibility contrast imaging (DSC), and arterial spin labelling (ASL). In DSC, Gadolinium contrast agent (Gd) is injected (usually intravenously) and a time series of fast T2*-weighted images is acquired. As Gadolinium passes through the tissues, it induces a reduction of T2* in the nearby water protons; the corresponding decrease in signal intensity observed depends on the local Gd concentration, which may be considered a proxy for perfusion. The acquired time series data are then postprocessed to obtain perfusion maps with different parameters, such as BV (blood volume), BF (blood flow), MTT (mean transit time) and TTP (time to peak). DCE-MRI also uses intravenous Gd contrast, but the time series is T1-weighted and gives increased signal intensity corresponding to local Gd concentration. Modelling of DCE-MRI yields parameters related to vascular permeability and extravasation transfer rate (see main article on perfusion MRI). Arterial spin labelling (ASL) has the advantage of not relying on an injected contrast agent, instead inferring perfusion from a drop in signal observed in the imaging slice arising from inflowing spins (outside the imaging slice) having been selectively saturated. A number of ASL schemes are possible, the simplest being flow alternating inversion recovery (FAIR) which requires two acquisitions of identical parameters with the exception of the out-of-slice saturation; the difference in the two images is theoretically only from inflowing spins, and may be considered a 'perfusion map'.