Objective: to determine whether liver computed tomography (CT) perfusion imaging can assess hemodynamics in patients with fibrosis and cirrhosis as a result of chronic viral hepatitis C (CVHC). Subjects and methods. The prospective study conducted at the Department of Radiation Diagnosis, M.F. Vladimirsky Moscow Regional Research and Clinical Institute, enrolled 61 patients with liver fibrosis and cirrhosis as a result of CVHC, of whom 26 patients had received antiviral therapy (AVT) and achieved a sustained virological response (SVR) at 24 weeks after the end of treatment. All the patients underwent liver CT perfusion imaging on a 256-slice Philips ICT computed tomography scanner (Netherlands). The parameters of arterial, portal, general perfusion and hepatic perfusion index were measured in each patient in his/her liver segments III, VII, and VIII, by calculating the slope of a curve. Results. The values of perfusion parameters in patients who had undergone AVT and attained SVR and who had received no specific treatment were compared with those in the fibrosis, compensated, subcompensated, and decompensated liver cirrhosis groups. In the liver fibrosis group, the patients who had achieved SVR after AVT had higher portal and total perfusion values than those who had received no specific treatment (p = 0.001 and p = 0.002; respectively). In the same group, the liver perfusion index was higher in the patients who had not undergone AVT than in the treated patients (p = 0.028). The values of total perfusion were statistically significantly higher in patients with compensated liver cirrhosis who had attained SVR after AVT than in the untreated patients (p = 0.008). In the decompensated liver cirrhosis group, portal perfusion after specific treatment was higher than in the non-AVT group (p = 0.012). The subcompensated liver cirrhosis group showed no statistically significant differences when comparing the values of liver perfusion parameters depending on the availability of treatment. Conclusion. Liver CT perfusion imaging cannot give an idea of how the hemodynamics of liver tissue changes in the presence of fibrosis and cirrhosis in patients with CVHC after AVT.

К л и н и ч е с к о е н а б л ю д е н и е Сташук Галина Александровнад-р мед. наук, заведующая рентгенологическим отделением № 2, профессор кафедры лучевой диагностики факультета усовершенствования врачей 1 ; ORCID:

Portal vein thrombosis is one of the most common complications of liver cirrhosis, the risk factors for which are still not fully understood.Purpose: to develop a prognostic model to determine the likelihood of portal vein thrombosis based on anamnestic, etiological factors, the presence of hepatocellular carcinoma, as well as parameters of CT perfusion of liver tissue.Material and methods. 43 patients with compensated liver cirrhosis (58.1% of men) and 38 patients with subcompensated liver cirrhosis (50% of men) were included in the prospective study. The age of patients in the first group was 52.56 ± 9.62 years, in the second group - 50.95 ± 9.94 years. The number of patients with 1 etiological factor of liver cirrhosis in the study groups was 62.8% and 81.5%, respectively. Type 2 diabetes mellitus was exhibited in 23.3% of patients with compensated liver cirrhosis and in 15.8% of patients with subcompensated liver cirrhosis. The diagnosis of hepatocellular carcinoma was established in 27.9% of patients with compensated liver cirrhosis and in 18.4% of patients with subcompensated liver cirrhosis. All patients, after the native study, underwent CT perfusion of the liver using a 256-slice Philips ICT apparatus. As a result of postprocessing, the values of arterial, portal, total perfusion and perfusion index of liver tissue were determined. Statistical analysis of the data was carried out using the binary logistic regression method and the construction of ROC curves.Results. A logistic stepwise multivariate analysis showed that an increase in arterial perfusion (p = 0.002) and a decrease in portal perfusion (p = 0.004) were independently associated with portal vein thrombosis in patients with compensated liver cirrhosis, and a history of primary liver cancer (p < 0.001) was a dependent factor in this model. In patients with subcompensated liver cirrhosis, a history of hepatocellular carcinoma (p < 0.001) and a decrease in portal perfusion (p = 0.001) became independent predictors of portal vein thrombosis, male gender (p = 0.029) was a dependent factor in the developed model.Conclusion. CT-perfusion of the liver makes it possible to determine predictors that can be used together with such factors as the presence of hepatocellular carcinoma and gender in the construction of prognostic models to determine the likelihood of portal vein thrombosis in patients with compensated and subcompensated liver cirrhosis. Age, etiological factor and the presence of type 2 diabetes mellitus in the developed models were not statistically significant.

Relevance: Most diffuse liver diseases lead to fibrosis over time with the risk of cirrhosis. With progressive fibrosis and cirrhosis of the liver both physical properties of the hepatic parenchyma and its hemodynamics change. The only reliable method for determining the stage of the disease is puncture biopsy and subsequent histological examination, but this method is invasive and associated with complications. Currently, the determination of the severity of cirrhosis is based on clinical data (the Child-Pugh scale) and elastography is considered to be the main non-invasive instrumental method. It lets reliably differentiate the initial fibrosis and cirrhosis of the liver, while the F2 and F3 stages according to the conventional METAVIR scale remain a "gray zone", as well as the differentiation of degrees of the severity of cirrhosis. In addition elastography has a  number of limitations. The main ones of which are operator dependence, apparatus dependence and the inability to determine functional changes in the liver. With the use of perfusion computed tomography (CT perfusion) it is possible to assess the functionality of the liver by quantifying changes in hemodynamics. The method applied measures the characteristics of blood flow in the tissue at a given scanning level by computed-tomographic data on the dynamics of the distribution of the contrast agent in the area of interest is collected, besides the type of liver perfusion is determined. This parameter is needed to assess the dynamics of treatment against the background of drug therapy.Objective: To identify statistically significant parameters of CT perfusion to determine the severity of hemodynamic disturbances in patients with various stages of liver fibrosis and cirrhosis and to compare the values of parameters of liver CT perfusion with fibrosis according to the METAVIR conditional scale determined using elastography.Materials and methods: 18  patients were included in this parallel pilot study. On the basis of clinical and laboratory data and the results of elastography, 10 of them were diagnosed with fibrosis and cirrhosis. The stages of fibrosis F1, F2 were determined in 3  patients; stages F3, F4  – in 7. In the group of patients with F3, F4, according to the METAVIR conditional scale, subgroups were distinguished depending on the severity of cirrhosis: compensated – 3 patients, subcompensated – 2, decompensated – 2. The control group consisted of 8 patients with organ diseases abdominal cavity not associated with liver damage. All patients underwent CT perfusion of the liver on a Philips iCT 256 using the following scan parameters: 80 KVp, 120 mAc, total scan time 56 s, and slice thickness 5.0 mm. Intravenously, bolus was administered to all patients with 50 ml of ioversol 350 mg/ml, the rate of administration was 3.8–4.0 ml/s, the time from the moment of administration of the contrast medium to the start of scanning was 6 s. After receiving a series of images, the data was processed on a Philips workstation. Quantitative analysis was carried out according to the following indicators: TTP (time to peak, s), BV (blood volume, ml/100 g), AP (arterial perfusion, ml/min/100 ml), PP (portal perfusion, ml/min/100  ml), TP (total perfusion, ml/min/100 ml) and HPI (hepatic perfusion index, %). Results: In the control group of 8  patients, the perfusion values were: TTP 37.4±5.2  s, BV 16.1±5.0 ml/100 g, AP 25.0±7.5 ml/min/100 ml, PP 44.5±14.5 ml/min/100 ml, TP 70.1±14.9 ml/min/100 ml, HPI 70.1±14.9%. In 3 patients with F1, F2, according to the METAVIR conditional scale, the following statistically significant values (p<0.039) of perfusion indices were determined: BV 27.2±8.6  ml/100  g, AP 20.0±3.8  ml/min/100  ml; with compensated liver cirrhosis (n=3): TTP 46.2±1.7  s, BV 12.4±1.9  ml/100  g, AP 10.7±2.8 ml/min/100 ml, PP 37.3±5.2 ml/min/100 ml, TP 48.1±3.5  ml/min/100  ml, HPI 22.4±5.5%; subcompensated (n=2): TTP 43.0±3.2  s, BV 8.9±2.6 ml/100 g, AP 12.8±3.0 ml/min/100 ml, PP 27.7±9.0 ml/min/100 ml, TP 40.5±7.3 ml/min/100 ml; decompensated (n=2): BV 30.5±1.8 ml/100 g, PP 8.5±1.5 ml/min/100 ml, HPI 81.3±1.8%.Conclusion: The preliminary results obtained confirm that CT perfusion can be used to predict and assess the severity of hemodynamic disturbances in patients with varying degrees of severity of cirrhosis and supplements clinical, laboratory and elastography data.