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Improved Diagnosis of Hepatic Perfusion Disorders: Value of Hepatic Arterial Phase Imaging during Helical CT¹

¹ From the Department of Radiology and Institut de Diagnòstic per la Imatge, Hospital General Universitari Vall d'Hebron, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain. Presented as a scientific exhibit at the 1999 RSNA scientific assembly. Received March 2, 2000; revision requested April 5 and received May 22; accepted May 26. Address correspondence to S.Q. (e-mail: squiroga@hg.vhebron.es).

View larger version (111K): [in a new window]   Figure 1.   Hepatic blood supply. Diagram shows that the arterial and venous supplies to the liver are not independent systems. There are numerous communications between them, including the transsinusoidal route (between the interlobular arterioles and portal venules or sinusoids) and the transplexal route (peribiliary plexus), which play an important role when portal venous inflow is compromised. Ao = aorta, GDA = gastroduodenal artery, HV = hepatic vein, IMV = inferior mesenteric vein, IVC = inferior vena cava, SMV = superior mesenteric vein.

View larger version (134K): [in a new window]   Figure 2a.   Portal vein thrombosis secondary to appendicitis in a 45-year-old woman. (a) CT scan shows transient high attenuation of the right hepatic lobe (arrow) due to obstruction of portal venous inflow and compensatory increase of the arterial inflow. (b) CT scan shows a bland thrombus within the right portal vein (arrow), which produces venous inflow obstruction.

View larger version (144K): [in a new window]   Figure 2b.   Portal vein thrombosis secondary to appendicitis in a 45-year-old woman. (a) CT scan shows transient high attenuation of the right hepatic lobe (arrow) due to obstruction of portal venous inflow and compensatory increase of the arterial inflow. (b) CT scan shows a bland thrombus within the right portal vein (arrow), which produces venous inflow obstruction.

View larger version (134K): [in a new window]   Figure 3a.   Right portal vein thrombosis secondary to abdominal trauma and a foreign body thrust into the hepatic parenchyma. CT was performed after the foreign body had been removed. (a) Helical CT scan shows the course of the foreign body (white arrow) through the right hepatic lobe, which is markedly enhanced during the arterial phase (arrowheads). Black arrow = left hepatic portal vein. (b) Helical CT scan shows thrombosis of the right portal vein (arrow) and THPE of the right hepatic lobe (arrowheads) secondary to compensatory increase of the arterial flow. (c) Shaded-surface display image shows the portal venous system with absence of the right portal vein. A = anterior, H = head, R = right, thick arrow = main portal vein, thin arrow = left portal vein. (d) Shaded-surface display image shows the hepatic parenchyma with arterial supply (red area) through two right hepatic arteries (arrows), one arising from the hepatic artery and the other from the superior mesenteric artery. A = anterior, H = head, R = right.

View larger version (127K): [in a new window]   Figure 3b.   Right portal vein thrombosis secondary to abdominal trauma and a foreign body thrust into the hepatic parenchyma. CT was performed after the foreign body had been removed. (a) Helical CT scan shows the course of the foreign body (white arrow) through the right hepatic lobe, which is markedly enhanced during the arterial phase (arrowheads). Black arrow = left hepatic portal vein. (b) Helical CT scan shows thrombosis of the right portal vein (arrow) and THPE of the right hepatic lobe (arrowheads) secondary to compensatory increase of the arterial flow. (c) Shaded-surface display image shows the portal venous system with absence of the right portal vein. A = anterior, H = head, R = right, thick arrow = main portal vein, thin arrow = left portal vein. (d) Shaded-surface display image shows the hepatic parenchyma with arterial supply (red area) through two right hepatic arteries (arrows), one arising from the hepatic artery and the other from the superior mesenteric artery. A = anterior, H = head, R = right.

View larger version (131K): [in a new window]   Figure 3c.   Right portal vein thrombosis secondary to abdominal trauma and a foreign body thrust into the hepatic parenchyma. CT was performed after the foreign body had been removed. (a) Helical CT scan shows the course of the foreign body (white arrow) through the right hepatic lobe, which is markedly enhanced during the arterial phase (arrowheads). Black arrow = left hepatic portal vein. (b) Helical CT scan shows thrombosis of the right portal vein (arrow) and THPE of the right hepatic lobe (arrowheads) secondary to compensatory increase of the arterial flow. (c) Shaded-surface display image shows the portal venous system with absence of the right portal vein. A = anterior, H = head, R = right, thick arrow = main portal vein, thin arrow = left portal vein. (d) Shaded-surface display image shows the hepatic parenchyma with arterial supply (red area) through two right hepatic arteries (arrows), one arising from the hepatic artery and the other from the superior mesenteric artery. A = anterior, H = head, R = right.

View larger version (123K): [in a new window]   Figure 3d.   Right portal vein thrombosis secondary to abdominal trauma and a foreign body thrust into the hepatic parenchyma. CT was performed after the foreign body had been removed. (a) Helical CT scan shows the course of the foreign body (white arrow) through the right hepatic lobe, which is markedly enhanced during the arterial phase (arrowheads). Black arrow = left hepatic portal vein. (b) Helical CT scan shows thrombosis of the right portal vein (arrow) and THPE of the right hepatic lobe (arrowheads) secondary to compensatory increase of the arterial flow. (c) Shaded-surface display image shows the portal venous system with absence of the right portal vein. A = anterior, H = head, R = right, thick arrow = main portal vein, thin arrow = left portal vein. (d) Shaded-surface display image shows the hepatic parenchyma with arterial supply (red area) through two right hepatic arteries (arrows), one arising from the hepatic artery and the other from the superior mesenteric artery. A = anterior, H = head, R = right.

View larger version (159K): [in a new window]   Figure 4a.   Transient high attenuation secondary to portal vein compression in a 52-year-old woman with an intrahepatic cholangiocarcinoma in the left lobe. (a) Preoperative maximum-intensity projection image shows the portal venous anatomy with absence of the left portal vein due to tumor invasion. Note the normal appearance of the anterior branch of the right portal vein (arrow). (b) Postoperative CT scan obtained during the HAP shows marked high attenuation of the anterior segments of the right hepatic lobe and a straight border (arrows). (c) CT scan obtained caudad to b shows a stricture of the anterior branch of the right portal vein (arrow) (cf a) and compensatory increase of hepatic arterial inflow.

View larger version (141K): [in a new window]   Figure 4b.   Transient high attenuation secondary to portal vein compression in a 52-year-old woman with an intrahepatic cholangiocarcinoma in the left lobe. (a) Preoperative maximum-intensity projection image shows the portal venous anatomy with absence of the left portal vein due to tumor invasion. Note the normal appearance of the anterior branch of the right portal vein (arrow). (b) Postoperative CT scan obtained during the HAP shows marked high attenuation of the anterior segments of the right hepatic lobe and a straight border (arrows). (c) CT scan obtained caudad to b shows a stricture of the anterior branch of the right portal vein (arrow) (cf a) and compensatory increase of hepatic arterial inflow.

View larger version (146K): [in a new window]   Figure 4c.   Transient high attenuation secondary to portal vein compression in a 52-year-old woman with an intrahepatic cholangiocarcinoma in the left lobe. (a) Preoperative maximum-intensity projection image shows the portal venous anatomy with absence of the left portal vein due to tumor invasion. Note the normal appearance of the anterior branch of the right portal vein (arrow). (b) Postoperative CT scan obtained during the HAP shows marked high attenuation of the anterior segments of the right hepatic lobe and a straight border (arrows). (c) CT scan obtained caudad to b shows a stricture of the anterior branch of the right portal vein (arrow) (cf a) and compensatory increase of hepatic arterial inflow.

View larger version (146K): [in a new window]   Figure 5a.   Portal venous laminar flow. (a) Helical CT scan shows THPE in both hepatic lobes (arrows). (b) Helical CT scan clearly shows laminar flow within the main portal vein (arrow), which is probably causing the THPE.

View larger version (150K): [in a new window]   Figure 5b.   Portal venous laminar flow. (a) Helical CT scan shows THPE in both hepatic lobes (arrows). (b) Helical CT scan clearly shows laminar flow within the main portal vein (arrow), which is probably causing the THPE.

View larger version (161K): [in a new window]   Figure 6a.   APS secondary to liver cirrhosis. (a) Helical CT scan obtained during the HAP shows early enhancement of the right portal vein branch (thick arrow), whereas the main portal vein remains nonenhanced (thin arrow). (b) Helical CT scan shows transient high attenuation (large arrow) in segment VI of the right hepatic lobe. Note the nonenhanced main portal vein (small arrow). (c) Maximum-intensity projection image shows early filling of the right portal vein branches (arrow).

View larger version (166K): [in a new window]   Figure 6b.   APS secondary to liver cirrhosis. (a) Helical CT scan obtained during the HAP shows early enhancement of the right portal vein branch (thick arrow), whereas the main portal vein remains nonenhanced (thin arrow). (b) Helical CT scan shows transient high attenuation (large arrow) in segment VI of the right hepatic lobe. Note the nonenhanced main portal vein (small arrow). (c) Maximum-intensity projection image shows early filling of the right portal vein branches (arrow).

View larger version (149K): [in a new window]   Figure 6c.   APS secondary to liver cirrhosis. (a) Helical CT scan obtained during the HAP shows early enhancement of the right portal vein branch (thick arrow), whereas the main portal vein remains nonenhanced (thin arrow). (b) Helical CT scan shows transient high attenuation (large arrow) in segment VI of the right hepatic lobe. Note the nonenhanced main portal vein (small arrow). (c) Maximum-intensity projection image shows early filling of the right portal vein branches (arrow).

View larger version (166K): [in a new window]   Figure 7a.   THPE in the left hepatic lobe secondary to liver cirrhosis. (a) Helical CT scan shows THPE in the left hepatic lobe with a straight border (small arrow) and early filling of the left portal vein (large arrow) similar to that of the adjacent left hepatic artery. (b) CT scan obtained caudad to a also shows THPE with a straight border (small arrow). Note that the right portal vein (large arrow) and main portal vein remain nonenhanced.

View larger version (162K): [in a new window]   Figure 7b.   THPE in the left hepatic lobe secondary to liver cirrhosis. (a) Helical CT scan shows THPE in the left hepatic lobe with a straight border (small arrow) and early filling of the left portal vein (large arrow) similar to that of the adjacent left hepatic artery. (b) CT scan obtained caudad to a also shows THPE with a straight border (small arrow). Note that the right portal vein (large arrow) and main portal vein remain nonenhanced.

View larger version (159K): [in a new window]   Figure 8a.   APS secondary to HCC. (a) Helical CT scan shows a 2-cm-diameter HCC in segment VII (curved arrow), which is difficult to distinguish because of distal transient, peripheral, wedge-shaped enhancement due to APS (straight arrows). Note also the small peripheral HCC in the left hepatic lobe (arrowhead). (b) Helical CT scan obtained during the HAP shows early enhancement of right portal vein branches (arrow) while the main portal vein remains nonenhanced. (c) Shaded-surface display image (anterosuperior view) shows early filling of the right portal vein branches (arrow) and transient enhanced hepatic parenchyma (blue area) due to APS. (Reprinted, with permission, from reference 17.)

View larger version (143K): [in a new window]   Figure 8b.   APS secondary to HCC. (a) Helical CT scan shows a 2-cm-diameter HCC in segment VII (curved arrow), which is difficult to distinguish because of distal transient, peripheral, wedge-shaped enhancement due to APS (straight arrows). Note also the small peripheral HCC in the left hepatic lobe (arrowhead). (b) Helical CT scan obtained during the HAP shows early enhancement of right portal vein branches (arrow) while the main portal vein remains nonenhanced. (c) Shaded-surface display image (anterosuperior view) shows early filling of the right portal vein branches (arrow) and transient enhanced hepatic parenchyma (blue area) due to APS. (Reprinted, with permission, from reference 17.)

View larger version (186K): [in a new window]   Figure 8c.   APS secondary to HCC. (a) Helical CT scan shows a 2-cm-diameter HCC in segment VII (curved arrow), which is difficult to distinguish because of distal transient, peripheral, wedge-shaped enhancement due to APS (straight arrows). Note also the small peripheral HCC in the left hepatic lobe (arrowhead). (b) Helical CT scan obtained during the HAP shows early enhancement of right portal vein branches (arrow) while the main portal vein remains nonenhanced. (c) Shaded-surface display image (anterosuperior view) shows early filling of the right portal vein branches (arrow) and transient enhanced hepatic parenchyma (blue area) due to APS. (Reprinted, with permission, from reference 17.)

View larger version (134K): [in a new window]   Figure 9a.   APS secondary to diffuse HCC in the right hepatic lobe. (a) Helical CT scan obtained during the HAP shows marked early enhancement of portal vein branches in both hepatic lobes and extensive THPE in the right lobe (arrows) secondary to APS, making detection of a tumor difficult. (b) Helical CT scan obtained during the PVP shows diffuse HCC in the right lobe and tumor thrombosis of a branch of the right portal vein (arrow).

View larger version (149K): [in a new window]   Figure 9b.   APS secondary to diffuse HCC in the right hepatic lobe. (a) Helical CT scan obtained during the HAP shows marked early enhancement of portal vein branches in both hepatic lobes and extensive THPE in the right lobe (arrows) secondary to APS, making detection of a tumor difficult. (b) Helical CT scan obtained during the PVP shows diffuse HCC in the right lobe and tumor thrombosis of a branch of the right portal vein (arrow).

View larger version (139K): [in a new window]   Figure 10.   APS secondary to hepatic hemangioma. Helical CT scan obtained during the HAP shows a small, homogeneous lesion (arrow) of high attenuation (similar to that of the aorta) with distal wedge-shaped parenchymal enhancement (arrowhead), an appearance corresponding to a small APS.

View larger version (156K): [in a new window]   Figure 11.   APS secondary to hepatic biopsy. CT scan obtained during the HAP shows peripheral, wedge-shaped enhancement (arrow) as the only sign of APS.

View larger version (171K): [in a new window]   Figure 12.   APS in a 25-year-old man with toxic hepatitis secondary to antituberculous therapy, acute liver failure, and a heterotopic liver transplant. Percutaneous biopsy of the native liver after graft removal resulted in a peripheral APS. Helical CT scan obtained during the HAP shows early enhancement of a small branch of the right portal vein (large arrow), indicative of an APS, and THPE (small arrows) in segment VI. Follow-up CT performed 9 months later showed spontaneous resolution of the arterioportal fistula.

View larger version (158K): [in a new window]   Figure 13.   Transient hepatic attenuation difference due to APS in a 64-year-old man with obstructive jaundice after percutaneous transhepatic biliary drainage. Helical CT scan shows a hyperattenuating area (arrows) corresponding to an APS affecting hepatic segments V and VIII. The APS was confirmed with celiac angiography and treated with embolization.

View larger version (137K): [in a new window]   Figure 14.   HHT in a 60-year-old man with a family history of HHT, repeated episodes of epistaxis, and telangiectases on the skin and mucosa. Results of liver function tests were normal. Helical CT was performed to investigate vague epigastric pain. CT scan obtained during the HAP shows dilated and tortuous intrahepatic arterial branches (arrows) and mosaic perfusion of the hepatic parenchyma with multiple transient enhancing areas, an appearance that probably corresponds to multiple APSs. On images obtained during the PVP, the liver was homogeneous and the hepatic veins were not dilated.

View larger version (119K): [in a new window]   Figure 15a.   HHT in a 66-year-old man with a family history of HHT and nasopharyngeal bleeding. Abdominal US was performed to investigate recurrent vague epigastric pain. The results of three hepatic biopsies in this area were normal. The results of liver function tests were also normal. (a) Transverse US scan shows a heterogeneous hepatic parenchyma with a subdiaphragmatic hypoechoic pseudonodular area (arrow). (b) Helical CT scan obtained during the HAP shows marked heterogeneous (reticular-mosaic) enhancement with multiple peripheral, wedge-shaped areas of transient enhancement, especially in segments VII and VIII, an appearance that probably corresponds to APSs. On images obtained during the PVP, no abnormalities were seen and the hepatic veins were not dilated. The hypoechoic areas on the US scan (a) probably correspond to focal sparing of fatty infiltration in the areas where APSs are present.

View larger version (143K): [in a new window]   Figure 15b.   HHT in a 66-year-old man with a family history of HHT and nasopharyngeal bleeding. Abdominal US was performed to investigate recurrent vague epigastric pain. The results of three hepatic biopsies in this area were normal. The results of liver function tests were also normal. (a) Transverse US scan shows a heterogeneous hepatic parenchyma with a subdiaphragmatic hypoechoic pseudonodular area (arrow). (b) Helical CT scan obtained during the HAP shows marked heterogeneous (reticular-mosaic) enhancement with multiple peripheral, wedge-shaped areas of transient enhancement, especially in segments VII and VIII, an appearance that probably corresponds to APSs. On images obtained during the PVP, no abnormalities were seen and the hepatic veins were not dilated. The hypoechoic areas on the US scan (a) probably correspond to focal sparing of fatty infiltration in the areas where APSs are present.

View larger version (134K): [in a new window]   Figure 16.   Hepatic abscess. CT scan shows THPE (arrows) around a large hepatic abscess owing to local inflammatory change in the affected hepatic parenchyma.

View larger version (119K): [in a new window]   Figure 17a. Acute cholecystitis in a 57-year-old woman. (a) Helical CT scan shows transient focal increased attenuation around the gallbladder fossa (arrows) in hepatic segments IV and V. (b) CT scan shows a thickened gallbladder wall (arrow).

View larger version (134K): [in a new window]   Figure 17b. Acute cholecystitis in a 57-year-old woman. (a) Helical CT scan shows transient focal increased attenuation around the gallbladder fossa (arrows) in hepatic segments IV and V. (b) CT scan shows a thickened gallbladder wall (arrow).

View larger version (128K): [in a new window]   Figure 18.   Cholangitis in a 63-year-old man. Helical CT scan shows THPE in a periportal location (arrows) secondary to cholangitis, an appearance reflecting hyperemic change around bile ducts.

View larger version (121K): [in a new window]   Figure 19a.   Transient hepatic attenuation difference due to an anatomic variant. (a) Helical CT scan shows an area of THPE in segment V (large arrow), adjacent to the gallbladder, with a markedly enhanced vein (small arrow). (b) CT scan obtained caudad to a shows the THPE in segment V even more clearly (arrow). No abnormalities were seen on images obtained during the PVP. This perfusion alteration probably corresponds to nonportal venous supply from the cystic vein.

View larger version (125K): [in a new window]   Figure 19b.   Transient hepatic attenuation difference due to an anatomic variant. (a) Helical CT scan shows an area of THPE in segment V (large arrow), adjacent to the gallbladder, with a markedly enhanced vein (small arrow). (b) CT scan obtained caudad to a shows the THPE in segment V even more clearly (arrow). No abnormalities were seen on images obtained during the PVP. This perfusion alteration probably corresponds to nonportal venous supply from the cystic vein.

View larger version (149K): [in a new window]   Figure 20.   Aberrant blood supply. Helical CT scan obtained during the HAP shows a triangular area of THPE in the dorsum of segment IV (arrow). No abnormalities were seen on images obtained during the PVP. This perfusion disorder probably corresponds to third hepatic inflow tracts (aberrant gastric venous drainage or parabiliary venous system).

View larger version (154K): [in a new window]   Figure 21.   Aberrant blood supply. CT scan shows THPE in segment III (arrow), adjacent to the stomach. Homogeneous hepatic parenchyma was demonstrated on nonenhanced and PVP images. The THPE is probably secondary to a third hepatic inflow tract (possibly aberrant gastric drainage).

View larger version (152K): [in a new window]   Figure 22a.   Perihepatic peritoneal implants of gastric carcinoma. (a) Helical CT scan shows THPE in segment IV (arrow) secondary to decreased portal venous perfusion due to compression of the hepatic parenchyma by perihepatic peritoneal implants. (b) CT scan shows a perihepatic implant causing THPE in segment VIII (arrow).

View larger version (158K): [in a new window]   Figure 22b.   Perihepatic peritoneal implants of gastric carcinoma. (a) Helical CT scan shows THPE in segment IV (arrow) secondary to decreased portal venous perfusion due to compression of the hepatic parenchyma by perihepatic peritoneal implants. (b) CT scan shows a perihepatic implant causing THPE in segment VIII (arrow).

View larger version (145K): [in a new window]   Figure 23.   Perihepatic fluid collection. CT scan shows THPE (arrows) secondary to compression of the hepatic parenchyma by a subphrenic-perihepatic abscess (*).

View larger version (171K): [in a new window]   Figure 24a.   Perfusion abnormalities in a 58-year-old man who was referred for work-up of bladder carcinoma. (a) Helical CT scan obtained during the HAP shows early enhancement in the margins of both lobes of the liver (arrows), an appearance that probably corresponds to an APS, irrespective of the cause. (b) CT scan obtained caudad to a shows similar findings. Nonenhanced CT scans and images obtained during the PVP showed a homogeneous parenchyma.

View larger version (174K): [in a new window]   Figure 24b.   Perfusion abnormalities in a 58-year-old man who was referred for work-up of bladder carcinoma. (a) Helical CT scan obtained during the HAP shows early enhancement in the margins of both lobes of the liver (arrows), an appearance that probably corresponds to an APS, irrespective of the cause. (b) CT scan obtained caudad to a shows similar findings. Nonenhanced CT scans and images obtained during the PVP showed a homogeneous parenchyma.

View larger version (132K): [in a new window]   Figure 25a.   Unexplained perfusion disorder in a 19-year-old woman who was referred for evaluation of upper gastrointestinal bleeding and multiple gastric submucosal masses corresponding to stromal tumors. (a) Helical CT scan shows multiple transient hyperattenuating areas (small arrows), some of which have nodular contours (large arrow). (b) Helical CT scan obtained caudad to a shows THPE (arrows) and multiple stromal tumors in the gastric wall (*). Corresponding PVP images showed homogeneous hepatic enhancement. No hepatic lesions were found at surgery, and the pseudolesions were absent at follow-up helical CT.

View larger version (136K): [in a new window]   Figure 25b.   Unexplained perfusion disorder in a 19-year-old woman who was referred for evaluation of upper gastrointestinal bleeding and multiple gastric submucosal masses corresponding to stromal tumors. (a) Helical CT scan shows multiple transient hyperattenuating areas (small arrows), some of which have nodular contours (large arrow). (b) Helical CT scan obtained caudad to a shows THPE (arrows) and multiple stromal tumors in the gastric wall (*). Corresponding PVP images showed homogeneous hepatic enhancement. No hepatic lesions were found at surgery, and the pseudolesions were absent at follow-up helical CT.