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Hepatic ECV was calculated from the delayed phase (5\u2009min post-contrast). Liver stiffness measurements (LSM) by transient elastography (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200979) and histological fibrosis grading (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200934) served as reference standards. Correlations were evaluated using Spearman\u2019s \u03c1, and multivariable linear regression was applied to identify independent associations with LSM. Diagnostic performance for CSPH was assessed with ROC analysis using guideline-endorsed LSM thresholds (\u2264\u200915\u2009kPa to rule out; \u2265\u200925\u2009kPa to rule in).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Hepatic PCCT-ECV showed strong correlations with fibrosis grade (\u03c1\u2009=\u20090.79,\n                      <jats:italic>p<\/jats:italic>\n                      &lt; 0.001) and LSM (\u03c1\u2009=\u20090.83,\n                      <jats:italic>p<\/jats:italic>\n                      &lt; 0.001). An ECV threshold of 27.7% identified CSPH (LSM\u2009\u2265\u200925\u2009kPa) with 95% sensitivity and 93% specificity. To rule out CSPH (LSM\u2009\u2264\u200915\u2009kPa), a threshold of 23.9% achieved 88% sensitivity and 97% specificity. In multivariable analysis including MELD score and platelet count, ECV remained independently associated with LSM. Inter-observer reproducibility was good (two-way random-effects, absolute agreement ICC\u2009=\u20090.83).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>PCCT-derived ECV provides a promising noninvasive biomarker for identifying or excluding CSPH in patients with chronic liver disease. Given its reproducibility and integration into routine HCC surveillance imaging, ECV may support early risk stratification. Validation in multicenter settings is warranted.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Key Points<\/jats:title>\n                    <jats:p>\n                      <jats:bold>\n                        <jats:italic>Question<\/jats:italic>\n                      <\/jats:bold>\n                      <jats:italic>Can a quantitative biomarker from routine CT scans reliably stratify risk for clinically significant portal hypertension, overcoming limitations of current noninvasive methods?<\/jats:italic>\n                    <\/jats:p>\n                    <jats:p>\n                      <jats:bold>\n                        <jats:italic>Findings<\/jats:italic>\n                      <\/jats:bold>\n                      <jats:italic>Photon-counting CT-derived ECV accurately stratifies portal hypertension risk, offering high sensitivity (95%) for rule-in and high specificity (97%) for rule-out.<\/jats:italic>\n                    <\/jats:p>\n                    <jats:p>\n                      <jats:bold>\n                        <jats:italic>Clinical relevance<\/jats:italic>\n                      <\/jats:bold>\n                      <jats:italic>Integrating PCCT-ECV into routine surveillance CT provides an opportunistic, noninvasive tool for CSPH risk stratification, guiding timely patient management without requiring a separate examination.<\/jats:italic>\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Graphical Abstract<\/jats:title>\n                  <\/jats:sec>","DOI":"10.1007\/s00330-025-12222-8","type":"journal-article","created":{"date-parts":[[2025,12,23]],"date-time":"2025-12-23T11:39:03Z","timestamp":1766489943000},"page":"3489-3500","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Photon-counting CT-derived hepatic extracellular volume quantification for noninvasive risk stratification of clinically significant portal hypertension (CSPH): a prospective cohort study"],"prefix":"10.1007","volume":"36","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2835-8560","authenticated-orcid":false,"given":"Tatjana","family":"Dell","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Verena","family":"Tischler","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dario","family":"Zocholl","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Narine","family":"Mesropyan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alice Margarida","family":"Jacob","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Johannes","family":"Chang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bernhard","family":"Schmidt","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claus Christian","family":"Pieper","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexander","family":"Isaak","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patrick","family":"Kupczyk","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carsten","family":"Meyer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julian","family":"Luetkens","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christian","family":"Strassburg","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christian","family":"Jansen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel","family":"Kuetting","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,12,23]]},"reference":[{"key":"12222_CR1","doi-asserted-by":"publisher","first-page":"151","DOI":"10.1016\/j.jhep.2018.09.014","volume":"70","author":"SK Asrani","year":"2019","unstructured":"Asrani SK, Devarbhavi H, Eaton J, Kamath PS (2019) Burden of liver diseases in the world. 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His role was limited to providing technical support for the imaging software. Siemens Healthcare GmbH had no role in the study design, data collection, data analysis, interpretation of the results, or the decision to submit the manuscript for publication. All other authors (Tatjana Dell, Verena Tischler, Dario Zocholl, Narine Mesropyan, Alice Margarida Jacob, Johannes Chang, Claus Christian Pieper, Alexander Isaak, Patrick Kupczyk, Carsten Meyer, Julian Luetkens, Christian Strassburg, Christian Jansen, and Daniel Kuetting) declare that they have no competing interests.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}},{"value":"Statistical analysis was performed by Dario Zocholl with support from Narine Mesropyan. Both are authors of this manuscript and have statistical expertise.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Statistics and biometry"}},{"value":"Written informed consent was obtained from all subjects (patients) in this study.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Informed consent"}},{"value":"This prospective study was conducted in accordance with the principles of the Declaration of Helsinki. The study protocol was approved by the responsible institutional review board (Ethics Committee of the Medical Faculty, University of Bonn, application number 254\/22).","order":6,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical approval"}},{"value":"No study subjects or cohorts have been previously reported.","order":7,"name":"Ethics","group":{"name":"EthicsHeading","label":"Study subjects or cohorts overlap"}},{"order":8,"name":"Ethics","group":{"name":"EthicsHeading","label":"Methodology"}}]}}