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    <div class="highwire-article-citation highwire-citation-type-highwire-article node11866--5" data-node-nid="11866" id="top-node-11866--6159531156" data-pisa="ajnr;33/4/E61" data-pisa-master="ajnr;ajnr.A3039" data-apath="/ajnr/33/4/E61.atom" data-hw-author-tooltip-instance="highwire_author_tooltip"><div class="highwire-cite highwire-cite-highwire-article highwire-citation-jcore-article-title-complete clearfix has-author-tooltip highwire-citation-highwire-article-top-a">
  
  
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      <h1 class="highwire-cite-title" id="page-title">CT Angiography Source Images with Modern Multisection CT Scanners: Delay Time from Contrast Injection to Imaging Determines Correlation with Infarct Core</h1>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0">B. Pulli</span> and <span class="highwire-citation-author" data-delta="1">A.J. Yoo</span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">April 2012,  </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">33 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(4) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E61; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata">DOI: https://doi.org/10.3174/ajnr.A3039 </span></div>
  
  
  
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<div id="hw-article-author-popups-top-node-11866--6159531156" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">B. Pulli </div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=B.%2BPulli%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Pulli%20B&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AB.%2BPulli%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div><div class="author-tooltip-1"><div class="author-tooltip-name">A.J. Yoo </div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=A.J.%2BYoo%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Yoo%20A&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AA.J.%2BYoo%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div></div></div>  </div>

  
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    <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" data-highwire-cite-ref-tooltip-instance="highwire_reflinks_tooltip" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article fulltext-view"><span class="highwire-journal-article-marker-start"></span><p id="p-1">We have read with great interest the letter by Dr Kloska<sup><a id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1</a></sup> and a subsequent reply<sup><a id="xref-ref-2-1" class="xref-bibr" href="#ref-2">2</a></sup> concerning a study by Sharma et al,<sup><a id="xref-ref-3-1" class="xref-bibr" href="#ref-3">3</a></sup> investigating the perfusion imaging correlate of CTA source image (CTA-SI) lesions and would like to share our own data on this subject. On the basis of our findings, we agree with Dr Kloska that evaluation of acute ischemia with CTA-SI on state-of-the-art multisection CT scanners depends primarily on the imaging protocol.</p><p id="p-2">In a recent investigation at our institution,<sup><a id="xref-ref-4-1" class="xref-bibr" href="#ref-4">4</a></sup> we analyzed 100 patients with acute ischemic stroke who underwent CTA-SI by using 2 different acquisition protocols with close follow-up DWI. We correlated CTA-SI hypoattenuation volumes with concurrent DWI hyperintense volumes and found that with the older protocol designed for a 4- or 16-section CT scanner (<a id="xref-table-wrap-1-1" class="xref-table" href="#T1">Table</a>), CTA-SI volume correlated well with DWI volume. When a 64-section scanner was installed at our medical center, we modified our CTA acquisition protocol to improve arterial phase opacification (<a id="xref-table-wrap-1-2" class="xref-table" href="#T1">Table</a>), and this was associated with significant overestimation of concurrent DWI volumes. Analysis of the CTA protocol parameters revealed that a shorter time from contrast injection to imaging of the ischemic territory was the single best predictor of CTA-SI overestimation of the infarct core on DWI. Imaging too soon likely prevented the contrast from traversing the collaterals and reaching the infarct bed. Most interesting, atrial fibrillation was associated with CTA-SI overestimation with the older protocol, which used a fixed delay, presumably related to delayed contrast-arrival time from reduced cardiac output.</p><div class="table pos-float" id="T1"><div class="table-inline table-callout-links"><div class="callout"><span>View this table:</span><ul class="callout-links"><li class="view-inline first"><a href="" class="table-expand-inline" data-table-url="/highwire/markup/37866/expansion?postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed&amp;table-expand-inline=1" data-icon-position="" data-hide-link-title="0">View inline</a></li><li class="view-popup last"><a href="/highwire/markup/37866/expansion?width=1000&amp;height=500&amp;iframe=true&amp;postprocessors=highwire_tables%2Chighwire_reclass%2Chighwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed" class="colorbox colorbox-load table-expand-popup" rel="gallery-fragment-tables" data-icon-position="" data-hide-link-title="0">View popup</a></li></ul></div></div><div class="table-caption"><p id="p-3" class="first-child">Overview of CTA protocols used in previous CTA-SI studies of acute stroke</p><div class="sb-div caption-clear"></div></div></div><p id="p-7">Given these data, we conclude that CTA-SI, just like CT perfusion, requires protocol validation before being used to assess acute infarct size in clinical practice. Moreover, protocol parameters should be standardized. The Table illustrates the variable parameters that have been used in studies evaluating CTA-SI for acute ischemic stroke. Until these issues are fully addressed, CTA-SI should be used cautiously to inform treatment decisions in patients with acute ischemic stroke.</p><div class="section ref-list" id="ref-list-1"><h2>References</h2><ol class="cit-list ref-use-labels"><li><span class="ref-label">1.</span><a class="rev-xref-ref" href="#xref-ref-1-1" title="View reference 1. in text" id="ref-1">↵</a>

<div class="cit ref-cit ref-journal" id="cit-33.4.E61.1" data-doi="10.3174/ajnr.A2493"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Kloska</span>  <span class="cit-name-given-names">SP</span></span></li></ol><cite>. <span class="cit-article-title">CT angiographic source images with modern multisection CT scanners: appropriate injection protocol is crucial</span>. <abbr class="cit-jnl-abbrev">AJNR Am J Neuroradiol</abbr> <span class="cit-pub-date">2011</span>;<span class="cit-vol">32</span>: <span class="cit-fpage">E93</span>
</cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiYWpuciI7czo1OiJyZXNpZCI7czo4OiIzMi81L0U5MyI7czo0OiJhdG9tIjtzOjE5OiIvYWpuci8zMy80L0U2MS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li><li><span class="ref-label">2.</span><a class="rev-xref-ref" href="#xref-ref-2-1" title="View reference 2. in text" id="ref-2">↵</a>

<div class="cit ref-cit ref-journal" id="cit-33.4.E61.2" data-doi="10.3174/ajnr.A2510"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Aviv</span>  <span class="cit-name-given-names">RI</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Sharma</span>  <span class="cit-name-given-names">M</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Lee</span>  <span class="cit-name-given-names">TJ</span></span></li></ol><cite>. <span class="cit-article-title">Reply</span>. <abbr class="cit-jnl-abbrev">AJNR Am J Neuroradiol</abbr> <span class="cit-pub-date">2011</span>;<span class="cit-vol">32</span>: <span class="cit-fpage">E94</span>
</cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiYWpuciI7czo1OiJyZXNpZCI7czo4OiIzMi81L0U5NCI7czo0OiJhdG9tIjtzOjE5OiIvYWpuci8zMy80L0U2MS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li><li><span class="ref-label">3.</span><a class="rev-xref-ref" href="#xref-ref-3-1" title="View reference 3. in text" id="ref-3">↵</a>

<div class="cit ref-cit ref-journal" id="cit-33.4.E61.3" data-doi="10.3174/ajnr.A2282"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Sharma</span>  <span class="cit-name-given-names">M</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Fox</span>  <span class="cit-name-given-names">AJ</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Symons</span>  <span class="cit-name-given-names">S</span></span>, </li><li><span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">CT angiographic source images: flow- or volume-weighted?</span>
<abbr class="cit-jnl-abbrev">AJNR Am J Neuroradiol</abbr> <span class="cit-pub-date">2011</span>;<span class="cit-vol">32</span>: <span class="cit-fpage">359</span>–<span class="cit-lpage">64</span></cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiYWpuciI7czo1OiJyZXNpZCI7czo4OiIzMi8yLzM1OSI7czo0OiJhdG9tIjtzOjE5OiIvYWpuci8zMy80L0U2MS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-abstract">Abstract</span><span class="cit-sep cit-reflinks-variant-name-sep">/</span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li><li><span class="ref-label">4.</span><a class="rev-xref-ref" href="#xref-ref-4-1" title="View reference 4. in text" id="ref-4">↵</a>

<div class="cit ref-cit ref-journal" id="cit-33.4.E61.4" data-doi="10.1148/radiol.11110896"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Pulli</span>  <span class="cit-name-given-names">B</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Schaefer</span>  <span class="cit-name-given-names">PW</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Hakimelahi</span>  <span class="cit-name-given-names">R</span></span>, </li><li><span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Acute ischemic stroke: infarct core estimation on CT angiography source images depends on CT angiography protocol</span>. <abbr class="cit-jnl-abbrev">Radiology</abbr> <span class="cit-pub-date">2012</span>;<span class="cit-vol">262</span>: <span class="cit-fpage">593</span>–<span class="cit-lpage">604</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1148/radiol.11110896&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=22187626&amp;link_type=MED&amp;atom=%2Fajnr%2F33%2F4%2FE61.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a></div></div></li><li><span class="ref-label">5.</span>

<div class="cit ref-cit ref-journal no-rev-xref" id="cit-33.4.E61.5" data-doi="10.1161/01.STR.0000032244.03134.37"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Schramm</span>  <span class="cit-name-given-names">P</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Schellinger</span>  <span class="cit-name-given-names">PD</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Fiebach</span>  <span class="cit-name-given-names">JB</span></span>, </li><li><span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Comparison of CT and CT angiography source images with diffusion-weighted imaging in patients with acute stroke within 6 hours after onset</span>. <abbr class="cit-jnl-abbrev">Stroke</abbr> <span class="cit-pub-date">2002</span>;<span class="cit-vol">33</span>: <span class="cit-fpage">2426</span>–<span class="cit-lpage">32</span></cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6OToic3Ryb2tlYWhhIjtzOjU6InJlc2lkIjtzOjEwOiIzMy8xMC8yNDI2IjtzOjQ6ImF0b20iO3M6MTk6Ii9ham5yLzMzLzQvRTYxLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-abstract">Abstract</span><span class="cit-sep cit-reflinks-variant-name-sep">/</span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li><li><span class="ref-label">6.</span>

<div class="cit ref-cit ref-journal no-rev-xref" id="cit-33.4.E61.6" data-doi="10.1161/01.STR.0000131271.54098.22"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Schramm</span>  <span class="cit-name-given-names">P</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Schellinger</span>  <span class="cit-name-given-names">PD</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Klotz</span>  <span class="cit-name-given-names">E</span></span>, </li><li><span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Comparison of perfusion computed tomography and computed tomography angiography source images with perfusion-weighted imaging and diffusion-weighted imaging in patients with acute stroke of less than 6 hours' duration</span>. <abbr class="cit-jnl-abbrev">Stroke</abbr> <span class="cit-pub-date">2004</span>;<span class="cit-vol">35</span>: <span class="cit-fpage">1652</span>–<span class="cit-lpage">58</span></cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6OToic3Ryb2tlYWhhIjtzOjU6InJlc2lkIjtzOjk6IjM1LzcvMTY1MiI7czo0OiJhdG9tIjtzOjE5OiIvYWpuci8zMy80L0U2MS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-abstract">Abstract</span><span class="cit-sep cit-reflinks-variant-name-sep">/</span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li><li><span class="ref-label">7.</span>

<div class="cit ref-cit ref-journal no-rev-xref" id="cit-33.4.E61.7" data-doi="10.1016/j.acra.2009.11.005"><div class="cit-metadata"><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Wittkamp</span>  <span class="cit-name-given-names">G</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Buerke</span>  <span class="cit-name-given-names">B</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Dziewas</span>  <span class="cit-name-given-names">R</span></span>, </li><li><span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Whole brain perfused blood volume CT: visualization of infarcted tissue compared to quantitative perfusion CT</span>. <abbr class="cit-jnl-abbrev">Acad Radiol</abbr> <span class="cit-pub-date">2010</span>;<span class="cit-vol">17</span>: <span class="cit-fpage">427</span>–<span class="cit-lpage">32</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1016/j.acra.2009.11.005&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=20060748&amp;link_type=MED&amp;atom=%2Fajnr%2F33%2F4%2FE61.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a></div></div></li></ol></div><ul class="copyright-statement"><li class="fn" id="copyright-statement-1">© 2012 by American Journal of Neuroradiology</li></ul><span class="highwire-journal-article-marker-end"></span></div><span class="related-urls"></span></div></div>  </div>

  
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        	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-volume highwire-cite-metadata">Vol. 33</span>, <span  class="highwire-cite-metadata-issue highwire-cite-metadata">Issue 4 </span><div  class="highwire-cite-metadata-pubdate highwire-cite-metadata">1 Apr 2012 </div></div>
      
      
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    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0"><span class="nlm-given-names">B.</span> <span class="nlm-surname">Pulli</span></span>, <span class="highwire-citation-author" data-delta="1"><span class="nlm-given-names">A.J.</span> <span class="nlm-surname">Yoo</span></span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">Apr 2012, </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">33 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(4) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E61; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata"><span class="label">DOI:</span> 10.3174/ajnr.A3039 </span></div>
  
  
  
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    <div class="highwire-article-citation highwire-citation-type-highwire-article node11866--3" data-node-nid="11866" id="share-node-11866--4372467399" data-pisa="ajnr;33/4/E61" data-pisa-master="ajnr;ajnr.A3039" data-apath="/ajnr/33/4/E61.atom"><div class="highwire-cite highwire-cite-highwire-article highwire-citation-jcore-standard clearfix">
  
  
  
  
      <div class="highwire-cite-title">CT Angiography Source Images with Modern Multisection CT Scanners: Delay Time from Contrast Injection to Imaging Determines Correlation with Infarct Core</div>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0"><span class="nlm-given-names">B.</span> <span class="nlm-surname">Pulli</span></span>, <span class="highwire-citation-author" data-delta="1"><span class="nlm-given-names">A.J.</span> <span class="nlm-surname">Yoo</span></span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">Apr 2012, </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">33 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(4) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E61; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata"><span class="label">DOI:</span> 10.3174/ajnr.A3039 </span></div>
  
  
  
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