BlueCross BlueShield of Tennessee Medical Policy Manual

Computed Tomography (CT) Perfusion Imaging

DESCRIPTION

Computed tomography (CT) perfusion imaging provides an assessment of cerebral blood flow that may assist in the identification of ischemic regions of the brain. This technology is proposed as a method to aid treatment decisions in individuals being evaluated for acute ischemic stroke, subarachnoid hemorrhage, cerebral vasospasm, brain tumors, and head trauma.

CT perfusion imaging performs by capturing images as an iodinated contrast agent bolus passes through the cerebral circulation and accumulates in the cerebral tissues. The quantitative perfusion parameters are calculated from density changes for each pixel over time with commercially available deconvolution-based software. It is estimated that a typical perfusion CT deposits a slightly greater radiation dose than a routine unenhanced head CT and covers limited areas of the brain.

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

In 2009, the U.S. Food and Drug Administration (FDA) issued a communication memo warning that individuals in multiple facilities were receiving excess radiation during perfusion CT imaging that aided in the diagnosis and treatment of strokes. The FDA continued in 2010 to investigate the scope and cause of the excess exposures and the potential health impact to the public and they have initiated recommendations to CT facilities and practitioners to review their perfusion imaging protocols.

In the absence of any well-designed randomized controlled trials addressing computed tomography (CT) perfusion imaging for neurological conditions, no conclusions can be drawn regarding clinical outcomes for these individuals.

SOURCES

American Heart Association. American Stroke Association. (2012). Guidelines for the management of aneurysmal subarachnoid hemorrhage: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Retrieved April 26, 2013 from http://stroke.ahajournals.org/content/43/6/1711.

American Heart Association. American Stroke Association. (2013). Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Retrieved April 26, 2013 from http://stroke.ahajournals.orgt/content/44/3/870.

BlueCross BlueShield Association. Medical Policy Reference Manual. (9:2012). Computed tomography (CT) perfusion imaging (6.01.49). Retrieved April 26, 2013 from BlueWeb. (27 articles and/or guidelines reviewed)

Silva, G. S., Lima, F. O., Camargo, E. C. S., Smith, W. S., Singhal, A. B., Greer, D. M., et al. (2010). Wake-up stroke: Clinical and neuroimaging characteristics. Cerebrovascular Disease, 29, 336-342.

U. S. Food and Drug Administration. (2008, June). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K081482. Retrieved July 7, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf8/K081482.pdf.

U. S. Food and Drug Administration. (2010, November). Center for Devices and Radiological Health. Medical devices. Safety investigation of CT brain perfusion scans: Update. Retrieved June 28, 2011 from http://www.fda.gov/medicaldevices/safety/alertsandnotices/ucm185898.htm.

ORIGINAL EFFECTIVE DATE:  12/10/2011  

MOST RECENT REVIEW DATE:  7/11/2013

ID_BA

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.