Contrast Staining may be Associated with Intracerebral Hemorrhage but Not Functional Outcome in Acute Ischemic Stroke Patients Treated with Endovascular Thrombectomy

Abstract

To evaluate the incidence of post-interventional contrast staining (PICS) in acute ischemic stroke (AIS) Chinese patients who were treated with endovascular thrombectomy (ET) and investigate potential association of PICS with functional outcome and intracerebral hemorrhage (ICH). This observational study was based on a single-center prospective registry study. AIS patients who underwent ET from January 2013 to February 2017 were recruited into this study. All patients had dual-energy CT (DECT) scan of the head at 12 to 24 hours post-ET. The primary outcome was the incidence of PICS. Secondary outcomes were total ICH, symptomatic ICH (sICH), 3-month functional outcome, and long-term functional outcome. One hundred and eighty patients were enrolled in this study. PICS was detected in 50 patients (28%) based on the post-interventional CT scan. We first used basic statistical analyses, showing that the incidence of both total ICH (60% vs. 25%, p<0.001) and sICH (18% vs. 8%, p=0.044) were higher in patients with PICS than those without, and fewer patients achieved no disability (mRS≤1) in the PICS group compared to the control group at both 3-month and long-term follow-up (p<0.01 each). However, multivariate regression analysis further revealed that PICS only increased total (adjusted odds ratio, 7.38; 95% confidence interval 1.66 to 32.9; p=0.009) but not sICH risk. Furthermore, the logistic regression analyses did not show statistical difference in good clinical outcomes or mortality between the two groups. PICS is a common phenomenon in Chinese AIS patients. It is associated with total ICH after ET, but it seems to have no effect on functional outcome and sICH. Further large-scale studies are warranted to validate these results.

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

“…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 ].…”

A Review of the Applications of Dual-Energy CT in Acute Neuroimaging

“…42 However, while contrast staining predicts intracranial hemorrhage, in another study it was not found to be associated with symptomatic hemorrhage or functional outcomes. 35…”

“…2,33 Parenchymal high attenuation is often seen immediately post-EVT due to disruption of the blood-brain barrier leading to iodine extravasation which causes contrast staining on CT. Differentiation between contrast staining and acute hemorrhage is difficult in single-energy CT as both appear hyperdense. 34 Dual-energy CT can differentiate parenchymal contrast staining from hemorrhage through generation of iodine overlay maps to isolate iodinated contrast and virtual noncontrast maps to subtract high attenuation due to iodine [34][35][36][37][38][39] (Figure 2). Use of DECT techniques changed the report from intracerebral hemorrhage to contrast staining in 34% of a series of post-EVT patients.…”

“…42 However, while contrast staining predicts intracranial hemorrhage, in another study it was not found to be associated with symptomatic hemorrhage or functional outcomes. 35 Postprocedural DECT may help to guide antiplatelet therapy in patients who have EVT and stenting of carotid occlusions to balance the risks of bleeding and stent thrombosis based on risk factors seen on DECT such as infarct size, contrast staining, and hemorrhage. 38 VNC images can also be used on post-EVT CT head to subtract residual contrast in the arteries and identify residual arterial thromboembolic material.…”

Contrast extravasation after angioplasty for symptomatic stenosis of the middle cerebral artery: A case report

“…It always presents as a hyperdensity on computed tomography (CT) imaging and thus is sometimes difficult to distinguish from intracerebral haemorrhage. 1 Previous studies have found that the hyperdense abnormalities detected on post-procedural CT scans may be a result of transitory disruption of the integrity of the blood-brain barrier (BBB), 2 which may be one of the reasons why contrast extravasation is common in patients with acute stroke. Studies have also demonstrated that contrast enhancement following neuroendovascular procedures may be associated with intracranial haemorrhage, consequently leading to poor prognoses in patients with acute ischaemic stroke.…”