Accuracy of perfusion-CT in predicting malignant middle cerebral artery brain infarction

J Neurol. 2008 Jun;255(6):896-902. doi: 10.1007/s00415-008-0802-1. Epub 2008 Mar 18.


Background: We performed a prospective study on patients with middle cerebral artery(MCA) ischemic stroke to evaluate the accuracy of perfusion-CT imaging(PCT) to predict the development of malignant brain infarction (MBI).

Methods: 106 patients(women 37 %, mean age 65 years)underwent native cranial computed tomography (CCT), CT angiography(CTA) and PCT after a median of 2 h after stroke onset. We assessed the patency of the MCA and the area of tissue ischemia (AIT)according to cerebral blood flow(CBF), cerebral blood volume (CBV) and time-to-peak (TTP)maps. Optimum sensitivity, specificity,positive (PPV) and negative predictive values (NPV) were calculated for the end-point MBI (= midline shift > 5 mm or decompressive surgery) by means of receiver operating characteristics(ROC).

Results: 20 patients (19 %)developed a MBI. In these patients,a larger AIT was found in all perfusion maps as compared to the remaining patients (p < 0.001). All perfusion maps had a very high NPV (95.4-98.4 %), a high sensitivity (85-95 %) and specificity (71.6-77.9 %) and only a moderate PPV (44-47.4 %). Best prediction was found for CBF maps with AIT of > 27.9 % of the hemisphere.

Conclusion: PCT allows the discrimination of patients without a relevant risk for MBI from those having a 50 % risk of MBI development. Due to the high sensitivity and specificity, PCT is a reliable tool in detecting MBI. Because of PCT's better availability, it is the method of choice at present for an early risk stratification of acute stroke patients.

Publication types

  • Case Reports
  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Brain / blood supply
  • Brain / diagnostic imaging
  • Brain / pathology
  • Brain Infarction / diagnostic imaging*
  • Brain Infarction / pathology*
  • Brain Infarction / physiopathology
  • Cerebral Angiography / methods
  • Cerebral Angiography / statistics & numerical data*
  • Cerebrovascular Circulation / physiology
  • Contrast Media
  • Diagnosis, Differential
  • Female
  • Humans
  • Image Processing, Computer-Assisted
  • Infarction, Middle Cerebral Artery / diagnostic imaging*
  • Infarction, Middle Cerebral Artery / pathology*
  • Infarction, Middle Cerebral Artery / physiopathology
  • Male
  • Middle Aged
  • Middle Cerebral Artery / diagnostic imaging
  • Middle Cerebral Artery / pathology
  • Middle Cerebral Artery / physiopathology
  • Predictive Value of Tests
  • Prognosis
  • Risk Factors
  • Tomography, X-Ray Computed / methods
  • Tomography, X-Ray Computed / statistics & numerical data*


  • Contrast Media