CC BY-NC-ND 4.0 · Asian J Neurosurg 2023; 18(04): 751-760
DOI: 10.1055/s-0043-1774820
Original Article

Role of Permeability Surface Area Product in Grading of Brain Gliomas using CT Perfusion

Ira Agrawal
1   Department of Radiodiagnosis, PGIMER, Dr. RML Hospital, New Delhi, India
Shahina Bano
1   Department of Radiodiagnosis, PGIMER, Dr. RML Hospital, New Delhi, India
2   Department of Neurosurgery, PGIMER, Dr. RML Hospital, New Delhi, India
Arvind Ahuja
3   Department of Pathology, PGIMER, Dr. RML Hospital, New Delhi, India
› Author Affiliations
Funding None.


Purpose The aim of this study was to evaluate the role of permeability surface area product in grading brain gliomas using computed tomography (CT) perfusion

Materials and Methods CT perfusion was performed on 33 patients with brain glioma diagnosed on magnetic resonance imaging. Of these, 19 had high-grade glioma and 14 had low-grade glioma on histopathological follow-up. CT perfusion values were obtained and first compared between the tumor region and normal brain parenchyma. Then the relative values of perfusion parameters were compared between high- and low-grade gliomas. Cut-off values, sensitivity, specificity, and strength of agreement for each parameter were calculated and compared subsequently. A conjoint factor (permeability surface area product + cerebral blood volume) was also evaluated since permeability surface area product and cerebral blood volume are considered complimentary factors for tumor vascularity.

Results All five perfusion parameters namely permeability surface area product, cerebral blood volume, cerebral blood flow, mean transit time, and time to peak were found significantly higher in the tumor region than normal brain parenchyma. Among these perfusion parameters, only relative permeability surface area product and relative cerebral blood volume were found significant in differentiating high- and low-grade glioma. Moreover, relative permeability surface area product was significantly better than all other perfusion parameters with highest sensitivity and specificity (97.74 and 100%, respectively, at a cut-off of 9.0065). Relative permeability surface area product had a very good agreement with the histopathology grade. The conjoint factor did not yield any significant diagnostic advantage over permeability surface area product.

Conclusion Relative permeability surface area product and relative cerebral blood volume were helpful in differentiating high- and low-grade glioma; however, relative permeability surface area product was significantly better than all other perfusion parameters. Grading brain gliomas using relative permeability surface area product can add crucial value in their management and prognostication; hence, it should be evaluated in the routine CT perfusion imaging protocol.

Ethical Statement

The study was conducted after obtaining ethical clearance from the institutional ethical committee. Informed consent was obtained from all patients included in the study.

Publication History

Article published online:
07 November 2023

© 2023. Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

  • References

  • 1 Dasgupta A, Gupta T, Jalali R. Indian data on central nervous tumors: a summary of published work. South Asian J Cancer 2016; 5 (03) 147-153
  • 2 Mesfin FB, Al-Dhahir MA. Cancer, Brain Gliomas. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2019
  • 3 Altwairgi AK, Raja S, Manzoor M. et al. Management and treatment recommendations for World Health Organization Grade III and IV gliomas. Int J Health Sci (Qassim) 2017; 11 (03) 54-62
  • 4 Law M, Yang S, Wang H. et al. Glioma grading: sensitivity, specificity, and predictive values of perfusion MR imaging and proton MR spectroscopic imaging compared with conventional MR imaging. AJNR Am J Neuroradiol 2003; 24 (10) 1989-1998
  • 5 Johnson DR, Guerin JB, Giannini C, Morris JM, Eckel LJ, Kaufmann TJ. 2016 updates to the WHO Brain Tumor Classification System: what the radiologist needs to know. Radiographics 2017; 37 (07) 2164-2180
  • 6 Law M, Young RJ, Babb JS. et al. Gliomas: predicting time to progression or survival with cerebral blood volume measurements at dynamic susceptibility-weighted contrast-enhanced perfusion MR imaging. Radiology 2008; 247 (02) 490-498
  • 7 Jain RK, Munn LL, Fukumura D. Dissecting tumour pathophysiology using intravital microscopy. Nat Rev Cancer 2002; 2 (04) 266-276
  • 8 Folkman J. The role of angiogenesis in tumor growth. Semin Cancer Biol 1992; 3 (02) 65-71
  • 9 Jain R, Ellika SK, Scarpace L. et al. Quantitative estimation of permeability surface-area product in astroglial brain tumors using perfusion CT and correlation with histopathologic grade. AJNR Am J Neuroradiol 2008; 29 (04) 694-700
  • 10 Ellika SK, Jain R, Patel SC. et al. Role of perfusion CT in glioma grading and comparison with conventional MR imaging features. AJNR Am J Neuroradiol 2007; 28 (10) 1981-1987
  • 11 Shankar JJ, Woulfe J, Silva VD, Nguyen TB. Evaluation of perfusion CT in grading and prognostication of high-grade gliomas at diagnosis: a pilot study. AJR Am J Roentgenol 2013; 200 (05) W504-9
  • 12 Hardee ME, Zagzag D. Mechanisms of glioma-associated neovascularization. Am J Pathol 2012; 181 (04) 1126-1141
  • 13 Xyda A, Haberland U, Klotz E. et al. Brain volume perfusion CT performed with 128-detector row CT system in patients with cerebral gliomas: a feasibility study. Eur Radiol 2011; 21 (09) 1811-1819
  • 14 Ding B, Ling HW, Chen KM, Jiang H, Zhu YB. Comparison of cerebral blood volume and permeability in preoperative grading of intracranial glioma using CT perfusion imaging. Neuroradiology 2006; 48 (10) 773-781
  • 15 Maarouf R, Sakr H. A potential role of CT perfusion parameters in grading of brain gliomas. Egypt J Radiol Nucl Med 2015; 46: 1119-1128
  • 16 Kumar S, Ramesh D, Kailasanathan N. The role of CT perfusion in grading of brain gliomas in correlation with histopathology. Int J Contemp Med Res 2017; 4 (02) 540-544
  • 17 Saleh TMR, Zakaria YM, Elnekidey AA, Farhoud AH, Ismail AS. Role of CT perfusion in differentiation between high and low grade glioma. Journal of Medical Science and Clinical Research 2015; 3 (11) 8392-8398
  • 18 Silvennoinen HM, Hamberg LM, Valanne L, Hunter GJ. Increasing contrast agent concentration improves enhancement in first-pass CT perfusion. AJNR Am J Neuroradiol 2007; 28 (07) 1299-1303
  • 19 Jain R, Gutierrez J, Narang J. et al. In vivo correlation of tumor blood volume and permeability with histologic and molecular angiogenic markers in gliomas. AJNR Am J Neuroradiol 2011; 32 (02) 388-394