Contrast Extravasation After Endovascular Treatment in Posterior Circulation Stroke

Sun, Yijia; Su, Yingying; Chen, Zhongyun; He, Yanbo; Zhang, Yingbo; Chen, Hongbo

doi:10.1016/j.wneu.2019.06.156

Cited by 10 publications

(8 citation statements)

References 21 publications

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“…Phan et al concluded on a series of 42 patients that DECT accurately differentiates between contrast and blood, but that metallic streak and calcifications could lead to identification failure [ 12 ]. This was supported by later studies [ 6 , 7 , 23 ].…”

Section: Reviewsupporting

confidence: 78%

Contrast Extravasation Post Thrombectomy in Patients With Acute Cerebral Stroke: A Review and Recommendations for Future Studies

Whitney

Khan

Alastra

et al. 2020

Cureus

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Mechanical thrombectomy (MT) for cerebral revascularization in acute stroke is now considered standard of care in select patients. Patients are assessed routinely after MT with CT scanning. The phenomenon of contrast staining is well documented in the literature and is posited to be related to increased blood-brain barrier (BBB) permeability of susceptible and/or infarcting brain tissue allowing angiographic contrast to be visualized outside the normal cerebral vasculature. In some cases, this can progress to include frank blood/contrast extravasation or even more seriously lead to intraparenchymal hemorrhage (IPH) with less favorable clinical outcomes. The relationship of this staining phenomenon and how it may have a cause or effect relationship with progression to hemorrhage is unclear. Many studies have been performed trying to better characterize this radiographic finding in terms of accurate diagnosis and potential for influencing prognosis. A literature review included a glaring lack of standardization in the application of terminology and quantitative/qualitative analysis. Dual energy CT (DECT) appears to be the best imaging modality to differentiate blood from contrast, but its application is limited since it is not as available as conventional CT. The possibility that risk factors are associated with progression of mixed density (blood and contrast) extravasations to frank IPH with resultant poorer outcomes is suggested in some studies. Overall, there remains a lack of consensus on how to best interpret this radiographic finding in altering any future stroke treatment(s). Recommendations of how to overcome this are postulated by the authors, which include standardization of terminology, progression toward more DECT use.

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Section: Reviewsupporting

confidence: 78%

Contrast Extravasation Post Thrombectomy in Patients With Acute Cerebral Stroke: A Review and Recommendations for Future Studies

Whitney

Khan

Alastra

et al. 2020

Cureus

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“…29 Moreover, 10% to 27% of patients overall have evidence of residual contrast on routine 24-hour CT brain. [28][29][30] Although excluding patients with visible hyperdensity artefacts may improve accuracy of NWU, the accuracy and interrater agreement of subjective visual assessment of blood or contrast and manual segmentation to exclude voxels contaminated by hyperdense material is not established. Restricting its application to patients without hemorrhagic transformation would also substantially reduce the method's generalizability on follow-up imaging by excluding up to 50% of patients.…”

Section: Discussionmentioning

confidence: 99%

Correlation Between Computed Tomography-Based Tissue Net Water Uptake and Volumetric Measures of Cerebral Edema After Reperfusion Therapy

Yassi

Sharma

et al. 2022

Stroke

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Background: Cerebral edema after large hemispheric infarction is associated with poor functional outcome and mortality. Net water uptake (NWU) quantifies the degree of hypoattenuation on unenhanced-computed tomography (CT) and is increasingly used to measure cerebral edema in stroke research. Hemorrhagic transformation and parenchymal contrast staining after thrombectomy may confound NWU measurements. We investigated the correlation of NWU measured postthrombectomy with volumetric markers of cerebral edema and association with functional outcomes. Methods: In a pooled individual patient level analysis of patients presenting with anterior circulation large hemispheric infarction (core 80–300 mL or Alberta Stroke Program Early CT Score ≤5) in the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke trials) data set, cerebral edema was defined as the volumetric expansion of the ischemic hemisphere expressed as a ratio to the contralateral hemisphere(rHV). NWU and midline-shift were compared with rHV as the reference standard on 24-hour follow-up CT, adjusted for hemorrhagic transformation and the use of thrombectomy. Association between edema markers and day 90 functional outcomes (modified Rankin Scale) was assessed using ordinal logistic regression. Results: Overall (n=144), there was no correlation between NWU and rHV (r s =0.055, P =0.51). In sub-group analyses, a weak correlation between NWU with rHV was observed after excluding patients with any degree of hemorrhagic transformation (r s =0.211, P =0.015), which further improved after excluding thrombectomy patients (r s =0.453, P =0.001). Midline-shift correlated strongly with rHV in all sub-group analyses (r s >0.753, P =0.001). Functional outcome at 90 days was negatively associated with rHV (adjusted common odds ratio, 0.46 [95% CI, 0.32–0.65]; P <0.001) and midline-shift (adjusted common odds ratio, 0.85 [95% CI, 0.78–0.92]; P <0.001) but not NWU (adjusted common odds ratio, 1.00 [95% CI, 0.97–1.03]; P =0.84), adjusted for age, baseline National Institutes of Health Stroke Scale, and thrombectomy. Prognostic performance of NWU improved after excluding patients with hemorrhagic transformation and thrombectomy (adjusted odds ratio, 0.90 [95% CI, 0.80–1.02]; P =0.10). Conclusions: NWU correlated poorly with conventional markers of cerebral edema and was not associated with clinical outcome in the presence of hemorrhagic transformation and thrombectomy. Measuring NWU postthrombectomy requires validation before implementation into clinical research. At present, the use of NWU should be limited to baseline CT, or follow-up CT only in patients without hemorrhagic transformation or treatment with thrombectomy.

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“…In the early phase after mechanical thrombectomy, conventional CT has a limited ability to differentiate IPH from iodinated contrast extravasation [11,[39][40][41]. From a pathophysiological standpoint, contrast extravasation is caused by a breakdown of the blood-brain barrier [42]. The early differentiation between IPH and iodinated contrast extravasation is important for the adjustment of therapy after mechanical thrombectomy, which will determine whether anticoagulation or antiplatelet therapy should be performed as early as possible [16,17].…”

Section: Discussionmentioning

confidence: 99%

CT-based radiomics for differentiating intracranial contrast extravasation from intraparenchymal haemorrhage after mechanical thrombectomy

Chen

Zhou

et al. 2022

Eur Radiol

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Objective To develop a nonenhanced CT-based radiomic signature for the differentiation of iodinated contrast extravasation from intraparenchymal haemorrhage (IPH) following mechanical thrombectomy. Methods Patients diagnosed with acute ischaemic stroke who underwent mechanical thrombectomy in 4 institutions from December 2017 to June 2020 were included in this retrospective study. The study population was divided into a training cohort and a validation cohort. The nonenhanced CT images taken after mechanical thrombectomy were used to extract radiomic features. The maximum relevance minimum redundancy (mRMR) algorithm was used to eliminate confounding variables. Afterwards, least absolute shrinkage and selection operator (LASSO) logistic regression was used to generate the radiomic signature. The diagnostic performance of the radiomic signature was evaluated by the area under the curve (AUC), accuracy, specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV). Results A total of 166 intraparenchymal areas of hyperattenuation from 101 patients were used. The areas of hyperattenuation were randomly allocated to the training and validation cohorts at a ratio of 7:3. The AUC of the radiomic signature was 0.848 (95% confidence interval (CI) 0.780–0.917) in the training cohort and 0.826 (95% CI 0.705–0.948) in the validation cohort. The accuracy of the radiomic signature was 77.6%, with a sensitivity of 76.7%, a specificity of 78.9%, a PPV of 85.2%, and a NPV of 68.2% in the validation cohort. Conclusions The radiomic signature constructed based on initial post-operative nonenhanced CT after mechanical thrombectomy can effectively differentiate IPH from iodinated contrast extravasation. Key Points • Radiomic features were extracted from intraparenchymal areas of hyperattenuation on initial post-operative CT scans after mechanical thrombectomy. • The nonenhanced CT-based radiomic signature can differentiate IPH from iodinated contrast extravasation early. • The radiomic signature may help prevent unnecessary rescanning after mechanical thrombectomy, especially in cases where contrast extravasation is highly suggestive.

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Contrast Extravasation After Endovascular Treatment in Posterior Circulation Stroke

Cited by 10 publications

References 21 publications

Contrast Extravasation Post Thrombectomy in Patients With Acute Cerebral Stroke: A Review and Recommendations for Future Studies

Contrast Extravasation Post Thrombectomy in Patients With Acute Cerebral Stroke: A Review and Recommendations for Future Studies

Correlation Between Computed Tomography-Based Tissue Net Water Uptake and Volumetric Measures of Cerebral Edema After Reperfusion Therapy

CT-based radiomics for differentiating intracranial contrast extravasation from intraparenchymal haemorrhage after mechanical thrombectomy

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