The effects of peritumoural oedema on cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) were studied in 18 patients with alert consciousness. Hemispheric mean CBF was measured by performing first-pass radionuclide angiography using technetium-99m hexamethylpropylene amine oxime. CVR was measured as the percentage change from the baseline mean CBF value after acetazolamide administration. Patients were classified into three groups according to the severity of peritumoural oedema. The mean CBF of both hemispheres in each group was not significantly different from that of age-matched controls. CVR was preserved in patients with mild peritumoural oedema (n=6), but was significantly (P<0.01) reduced in patients with moderate (n=7) and severe peritumoural oedema (n=5). No significant correlation was found between the degree of midline shift and the mean CVR of both hemispheres (P=0.09). Surgical removal of the tumour significantly (P<0.05) improved the impaired CVR, although the mean CBF did not change. Administration of glucocorticoid improved the impaired CVR, without a change in the mean CBF, in a patient with a metastatic brain tumour. We conclude that CVR is impaired by the development of peritumoural oedema prior to changes in mean CBF.