Translent CT hyperattenuation after intraarterial thrombolysis in stroke. Contrast extravasation or hemorrhage

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1 Translent CT hyperattenuation after intraarterial thrombolysis in stroke. Contrast extravasation or hemorrhage Poster No.: C-0053 Congress: ECR 2013 Type: Scientific Exhibit Authors: A. Losa Palacios, J. D. Molina Nuevo, E. Julia Molla, M. J. Pedrosa Jiménez, D. Caldevilla Bernardo, A. Hernandez Castro; Albacete/ES Keywords: DOI: Haemorrhage, Embolism / Thrombosis, Thrombolysis, Contrast agent-intravenous, CT, Catheter arteriography, Neuroradiology brain, Interventional vascular /ecr2013/C-0053 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 20

2 Purpose This is a descriptive study about hyperdensities on post-treatment CT of intraarterial thrombolysis in patients with ischemic stroke to make a correct differential diagnosis between cerebral hemorrhage and extravasation of contrast. Page 2 of 20

3 Methods and Materials Three patients diagnosed with ischemic stroke underwent arterial thrombolysis, which was performed within hours. CT hyperdensities presented in the basal ganglia were monitored for control. Then the patients were assessed for the clinical significance of areas of CT hyperdensity seen post-treatment. Patient 1: 79-year-old woman admitted for right middle cerebral artery stroke of cardioembolic origin, possible chronic atrial fibrillation: treated with acenocoumarol. The CT scan (Figure 1) and subsequently arterial thrombolysis. Patient 2: 55-year-old male who presents with symptoms compatible with right middle cerebral artery stroke of cardioembolic origin possibly by unknown onset of atrial fibrillation. The CT scan (Figures 2 and 3) and subsequently arterial thrombolysis. Patient 3: 37-year-old male admitted with ischemic stroke in the territory of the left middle cerebral artery. The only known personal history is a previous hypercholesterolemia without other relevant history. He underwent a CT brain perfusion study (Figures ) Page 3 of 20

4 Images for this section: Fig. 1: Hyperdensity right middle cerebral artery. Page 4 of 20

5 Fig. 2: Hyperdensity right middle cerebral artery. Page 5 of 20

6 Fig. 3: Hypodensity in right lenticular nucleus Page 6 of 20

7 Fig. 4: Image hyperdense left middle cerebral artery prior to the entry into Sylvian fissure Page 7 of 20

8 Fig. 5: Hypodense areas of middle cerebral artery territory left ill-defined with effacement of cortico-subcortical differentiation in relation to acute ischemic injury Page 8 of 20

9 Fig. 6: Area of decreased blood flow in the anterior territory of the left middle cerebral artery of at least 20% Page 9 of 20

10 Fig. 7: TTM reduction zone in the anterior region of the left middle cerebral artery of at least 20% Page 10 of 20

11 Fig. 8: Area of decreased blood volume in anterior territory of the left middle cerebral artery of at least 20% Page 11 of 20

12 Results The presence of hyperdensities on CT after intraarterial thrombolysis is not always bleeding, because there may be extravasation of contrast. However, this may suggest some degree of microvascular damage and may predict the onset of further bleeding complications. In the three cases reported, two of them showed extravasation and the other cerebral hemorrhage. PATIENT 1: At 17 hours, thrombolysis was performed. CT showed right basal ganglia hyperdensity, poorly defined (Figure 9). This hyperdensity was practically resolved on the control CT performed after 48 hours, ensuring the results were free of contrast extravasation (Figure 10). Patient 2: At 24-hours intra-arterial thrombolysis was performed. CT showed right basal ganglia hyperdensity of 2.2 cm with perilesional edema (Figure 11) and left occipital horn hyperdensity with mass effect on frontal horn of the right lateral ventricle, these hyperdensities were related to cerebral hemorrhage in the basal ganglia (Figure 12). Patient 3: At 24-hours intra-arterial thrombolysis was performed. CT showed linear hyperdensity on distal M1 segment (Figure 13) which is continuous with adjacent hyperdensity of Sylvian fissure and minimal hyperdensity of the left basal ganglia (Figure 14 ) probably related to contrast extravasation. Page 12 of 20

13 Images for this section: Fig. 9: Hyperdensity poorly defined basal ganglia rights without perilesional edema related to contrast extravasation Page 13 of 20

14 Fig. 10: Almost complete resolution of contrast extravasation in basal ganglia TC rights performed at 48 hours prior. Page 14 of 20

15 Fig. 11: Basal ganglia hyperdensity rights with perilesional edema and compression to right lateral ventricle in relation to cerebral hemorrhage after arterial thrombolysis. Page 15 of 20

16 Fig. 12: Hemorrhage in basal ganglia and right ventricle blood in the left lateral occipital horn. Page 16 of 20

17 Fig. 13: Linear hyperdensity distal segment of the left middle cerebral artery in M1 segment related to contrast material retained. Page 17 of 20

18 Fig. 14: Adjacent hyperdensity Sylvian fissure and left basal ganglia related to contrast extravasacón after arterial thrombolysis. Page 18 of 20

19 Conclusion Although more than half of the CT hyperdensities after arterial thrombolysis are associated with a certain degree of microvascular damage from bleeding, only 1/3 present with symptomatic hemorrhage. If the damage only affects vascular endothelial cells, hyperdense areas could be contrast medium, but if the damage is more extensive and affects basal lamina as hyperdense areas, this may be associated with some degree of bleeding. The lenticular nuclei hyperdensities can develop into a massive hemorrhage. When located in the cerebral cortex, this represents a high incidence of hemorrhage, but usually these are petechial; therefore, when a lenticular nucleus hyperdensity is observed, one should alert the clinician to the importance of withdrawal of anticoagulant therapy to reduce the risk of development into a massive bleeding. Page 19 of 20

20 References The National Institute of Neurological Disorders and Stroke rt-pa Stroke Study Group. Tissue plasminogen activator for acute ischaemic stroke. N Engl J Med. 1995; 333: Wahlgren N., Ahmed N., Davalos A., Ford G.A., Grond M., Hacke W., et al. Trombolysis with alteplase for acute ischaemic stroke the Safe Implementation of Thrombolysis in Stroke-Monitoring study (SITS-MOST): An observational study. Lancet. 2007; 369: Thomalla G., SchwarK C., Sobesky J., Bluhmki E., Fiebach J.B., Fiehler J., et al, for the MRI in Acute Stroke Study Group of the German Competence Network Stroke. Outcome and symptomatic bleeding complications of intravenous thrombolysis within 6h in MRIselected stroke patients: Comparison of a German multicenter study with the pooled data of ATLANTIS, ECASS and NINDS tpa trials. Stroke. 2006; 37: Lisboa R.C., Jovanovic B.D., Alberts M.J. Analysis of the safety and efficacy of intraarterial thrombolytic therapy in ischemic stroke. Stroke. 2002; 33: Page 20 of 20