Metallic Hyperdensity Sign on Noncontrast CT Immediately after Mechanical Thrombectomy Predicts Parenchymal Hemorrhage in Patients with Acute Large-Artery Occlusion

Xu, Chao; Zhou, Ying; Zhang, R.; Chen, Z.; Zhong, Wansi; Gong, Xiaoxian; Ding, Xi; Lou, Min

doi:10.3174/ajnr.a6008

Cited by 19 publications

(24 citation statements)

References 30 publications

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“…10,18,19,21,35 A recent study has demonstrated that early subtle CT findings strongly predict hemorrhagic transformation, but it has not included areas of hyperdensity as a predictor. 5 Another recent study proposed a metallic hyperdense sign on CT performed immediately after thrombectomy, defined as a focal area superior to 1.0 cm in diameter with maximum CT density superior to 90 HU identified within the non-petechial intracerebral hyperdense lesion in the basal ganglia, which could predict the occurrence of parenchymal hemorrhage at 24 h. 27 However, a smaller cohort publication has questioned the use of density thresholds that would not allow a reliable differentiation between hemorrhage and contrast staining on immediate post-interventional CT. 11 In our cohort, we use the high-density sign without an HU threshold; however, logistic regression showed that increasing CT density significantly increases the odds of hemorrhage. Nevertheless, applying a density threshold of 90 HU did not reach high specificity and sensitivity (specificity of 77.0% and sensitivity of 42%).…”

Section: Discussionmentioning

confidence: 99%

“…Xu et al. have shown results using CT performed immediately after the procedure, whereas in our cohort, we have included CT performed up to 24 h. 27…”

Section: Discussionmentioning

confidence: 99%

“…defined hemorrhagic transformation as persistent contrast staining beyond 24 h. 16 However, contrast staining could still be relatively dense 24 h after thrombectomy, and the differentiation could be better with an extended series of follow-up after the intervention. 27 The most widely accepted hypothesis differentiate the high-density lesions based in the presence of degradation of the basal lamina, which would cause not only leakage of iodine contrast into the extracellular spaces but also some degree of hemorrhage. 28–31 Therefore, the previously used term contrast extravasation better reflects the presence of hemorrhage and impacts in the reported outcomes.…”

Section: Discussionmentioning

confidence: 99%

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Value of high-density sign on CT images after mechanical thrombectomy for large vessel occlusion in predicting hemorrhage and unfavorable outcome

et al. 2020

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Purpose Cerebral hyperdensities can appear on head computed tomography (CT) images performed early after endovascular treatment (EVT) in patients with acute ischemic stroke and may be secondary to contrast staining or hemorrhagic transformation. The aim of this study was to determine how the high-density sign on CT affects mortality and clinical outcome and whether CT parameters predict hemorrhagic conversion or unfavorable outcome. Methods We retrospectively reviewed a database of patients who underwent EVT with mechanical thrombectomy for acute ischemic stroke over 7 years. Included were acute stroke patients with a CT examination within 24 h post-EVT with mechanical thrombectomy, demonstrating areas of hyperdensity. We evaluated morphologic characteristics of these lesions, location, CT Hounsfield units and largest area, as well as patient demographics, EVT methods and patient outcome. Results A total of 29 patients met the strict inclusion criteria. Complete recanalization was achieved in 58.6% (17/29). Seventeen (58.6%) cases of post-intervention cerebral hyperdensities were related to contrast staining and 12 (41.4%) cases to contrast staining and hemorrhage. Patient mortality was significantly higher in the hemorrhagic group (50.0% versus 5.9%, p = 0.003). The increased density on CT was associated with higher hemorrhagic risk (odds ratio 1.05, p = 0.036). Conclusion Patients with the high-density sign on CT images after mechanical thrombectomy for acute ischemic stroke demonstrated increased mortality and worse clinical outcome, primarily when these hyperdensities were related to hemorrhage. CT imaging parameters as higher density areas can help in the differentiation of hemorrhage from contrast staining.

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Section: Discussionmentioning

confidence: 99%

“…Xu et al. have shown results using CT performed immediately after the procedure, whereas in our cohort, we have included CT performed up to 24 h. 27…”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Value of high-density sign on CT images after mechanical thrombectomy for large vessel occlusion in predicting hemorrhage and unfavorable outcome

et al. 2020

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“…Xu et al conducted a retrospective study on 59 patients who had ‘metallic hyperdensity sign’ defined as a diameter greater than 1 cm in the basal ganglia and HU greater than 90 and concluded, with 90.5% specificity and a negative predictive value of 95.7%, conversion to parenchymal hemorrhage [ 19 ].…”

Section: Reviewmentioning

confidence: 99%

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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“…In some hospitals, immediate non-contrast enhanced computed tomography (NCCT) has been used to assess potential early complications due to a relatively higher risk of reperfusion injury, especially in patients with long procedure duration 7–12. Following MT of an acute LVO, hyperattenuated lesions are frequently found on NCCT immediately after interventional procedures 7–129.…”

Section: Introductionmentioning

confidence: 99%

Association of maximal systolic blood pressure with poor outcome in patients with hyperattenuated lesions on immediate NCCT after mechanical thrombectomy

Ding

Zhong

et al. 2019

J NeuroIntervent Surg

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Background and purposeThis study aimed to investigate the relationship between blood pressure (BP) management and clinical outcome in patients with hyperattenuated lesions on non-contrast CT (NCCT) immediately after mechanical thrombectomy (MT).MethodsWe retrospectively reviewed our prospectively collected cohort for consecutive patients with acute ischemic stroke (AIS) who received MT between October 2013 and July 2018. Hourly systolic BP (SBP) and diastolic BP (DBP) values were recorded for 24 hours following MT, and then maximum SBP (SBPmax) and DBP (DBPmax) values were identified. Poor outcome was defined as 3-month modified Rankin score (mRS) 3–6 and parenchymal hemorrhage (PH) was defined according to the European Cooperative Acute Stroke Study (ECASS) II trial. Associations of BP parameters with poor outcome and PH were determined using binary logistic regression models. Receiver operating characteristics (ROC) curve analysis was used to determine the predictive value of BP.ResultsInitially 262 patients with AIS who received MT were reviewed and 148 patients with hyperattenuated lesions on immediate NCCT were enrolled in the final cohort for analysis. Binary logistic regression showed that every 10 mm Hg increase in SBPmax was independently associated with a poor outcome (OR 1.426; 95% CI 1.095 to 1.855; p=0.008) and PH (OR 1.025; 95% CI 1.005 to 1.480; p=0.044). SBP ≤140 mm Hg during the post-procedural 24-hour period was associated with lower odds of a poor outcome and PH compared with the other group.ConclusionsControl of maximal SBP within 24 hours might be related to a low rate of PH and poor outcome in patients with hyperattenuated lesions on immediate NCCT after intervention.

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Metallic Hyperdensity Sign on Noncontrast CT Immediately after Mechanical Thrombectomy Predicts Parenchymal Hemorrhage in Patients with Acute Large-Artery Occlusion

Cited by 19 publications

References 30 publications

Value of high-density sign on CT images after mechanical thrombectomy for large vessel occlusion in predicting hemorrhage and unfavorable outcome

Value of high-density sign on CT images after mechanical thrombectomy for large vessel occlusion in predicting hemorrhage and unfavorable outcome

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

Association of maximal systolic blood pressure with poor outcome in patients with hyperattenuated lesions on immediate NCCT after mechanical thrombectomy

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