CardioVascular and Interventional Radiology

, Volume 37, Issue 5, pp 1171–1178 | Cite as

Dual-energy CT Immediately after Endovascular Stroke Intervention: Prognostic Implications

  • D. Morhard
  • L. Ertl
  • W. Gerdsmeier-Petz
  • B. Ertl-Wagner
  • G. Schulte-Altedorneburg
Clinical Investigation

Abstract

Purpose

Posttreatment intracerebral hemorrhage (ICH) after recanalization therapy of acute ischemic stroke increases morbidity and mortality. Dual-energy (DE) computed tomography (CT) allows differentiation of blood–brain barrier disruption (BBBD) and ICH. We evaluated the incidence of ICH and BBBD immediately after endovascular recanalization therapy, the correlation between BBBD and final infarction or ICH size, and the prognostic value of postinterventional BBBD.

Methods

Imaging data sets (pretreatment CT, posttreatment DE-CT, and follow-up imaging by CT and/or magnetic resonance imaging) of 60 consecutive patients after endovascular recanalization therapy of acute ischemic stroke were retrospectively analyzed. After material differentiation, areas of increase attenuation in posttreatment DE-CT were correlated to ICH and infarction in follow-up imaging.

Results

Areas of hyperattenuation were observed in 80.0 % (48 of 60) of all posttreatment CT. In 10.4 % (5 of 48) of these, hyperattenuating areas matched the hyperdensities on virtual nonenhanced CT and were rated as hemorrhage. The remaining 89.6 % (43 of 48) of scans with hyperattenuating areas demonstrated hyperdensities exclusively on iodine-only images and were rated as BBBD. All suspected ICH on DE-CT were proven in follow-up imaging. There were no false-positive or false-negative findings of ICH in DE-CT. In 98.3 % (59 of 60) of cases, at least small ischemic infarctions were identified in follow-up imaging. No correlation between the extent of BBBD and the final infarct size and/or early ICH size was found.

Conclusion

BBBD is a frequent finding after endovascular revascularization therapy. DE-CT allows for a reliable differentiation between frequent BBBD and rare ICH immediately after endovascular recanalization therapy.

Keywords

Neurointerventions Stroke therapy Brain Neurological Nervous system Stroke 

References

  1. 1.
    Rha JH, Saver JL (2007) The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke 38:967–973PubMedCrossRefGoogle Scholar
  2. 2.
    Fesl G, Patzig M, Holtmannspoetter M et al (2012) Endovascular mechanical recanalisation after intravenous thrombolysis in acute anterior circulation stroke: the impact of a new temporary stent. Cardiovasc Intervent Radiol 35:1326–1331PubMedCrossRefGoogle Scholar
  3. 3.
    Koh JS, Lee SJ, Ryu CW, Kim HS (2012) Safety and efficacy of mechanical thrombectomy with solitaire stent retrieval for acute ischemic stroke: a systematic review. Neurointervention 7:1–9PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Machi P, Costalat V, Lobotesis K et al (2012) Solitaire FR thrombectomy system: immediate results in 56 consecutive acute ischemic stroke patients. J Neurointerv Surg 4:62–66PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Smith WS, Sung G, Saver J et al (2008) Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke 39:1205–1212PubMedCrossRefGoogle Scholar
  6. 6.
    Costalat V, Lobotesis K, Machi P et al (2012) Prognostic factors related to clinical outcome following thrombectomy in ischemic stroke (RECOST study). 50 patients prospective study. Eur J Radiol 81:4075–4082PubMedCrossRefGoogle Scholar
  7. 7.
    Molina CA (2010) Futile recanalization in mechanical embolectomy trials: a call to improve selection of patients for revascularization. Stroke 41:842–843PubMedCrossRefGoogle Scholar
  8. 8.
    Alexandrov AV, Black SE, Ehrlich LE et al (1997) Predictors of hemorrhagic transformation occurring spontaneously and on anticoagulants in patients with acute ischemic stroke. Stroke 28:1198–1202PubMedCrossRefGoogle Scholar
  9. 9.
    Hom J, Dankbaar JW, Soares BP et al (2011) Blood-brain barrier permeability assessed by perfusion CT predicts symptomatic hemorrhagic transformation and malignant edema in acute ischemic stroke. AJNR Am J Neuroradiol 32:41–48PubMedCrossRefGoogle Scholar
  10. 10.
    Fiorelli M, Bastianello S, von Kummer R et al (1999) Hemorrhagic transformation within 36 hours of a cerebral infarct: relationships with early clinical deterioration and 3-month outcome in the European Cooperative Acute Stroke Study I (ECASS I) cohort. Stroke 30:2280–2284PubMedCrossRefGoogle Scholar
  11. 11.
    Mokin M, Kan P, Kass-Hout T et al (2012) Intracerebral hemorrhage secondary to intravenous and endovascular intraarterial revascularization therapies in acute ischemic stroke: an update on risk factors, predictors, and management. Neurosurg Focus 32:E2PubMedCrossRefGoogle Scholar
  12. 12.
    t-PA Stroke Study Group TN (1997) Intracerebral hemorrhage after intravenous t-PA therapy for ischemic stroke. Stroke 28:2109–2118CrossRefGoogle Scholar
  13. 13.
    Greer DM, Koroshetz WJ, Cullen S et al (2004) Magnetic resonance imaging improves detection of intracerebral hemorrhage over computed tomography after intra-arterial thrombolysis. Stroke 35:491–495PubMedCrossRefGoogle Scholar
  14. 14.
    Johnson TR, Krauss B, Sedlmair M et al (2007) Material differentiation by dual energy CT: initial experience. Eur Radiol 17:1510–1517PubMedCrossRefGoogle Scholar
  15. 15.
    Gupta R, Phan CM, Leidecker C et al (2010) Evaluation of dual-energy CT for differentiating intracerebral hemorrhage from iodinated contrast material staining. Radiology 257:205–211PubMedCrossRefGoogle Scholar
  16. 16.
    Phan CM, Yoo AJ, Hirsch JA et al (2012) Differentiation of hemorrhage from iodinated contrast in different intracranial compartments using dual-energy head CT. AJNR Am J Neuroradiol 33:1088–1094PubMedCrossRefGoogle Scholar
  17. 17.
    Molina CA, Alvarez-Sabin J, Montaner J et al (2002) Thrombolysis-related hemorrhagic infarction: a marker of early reperfusion, reduced infarct size, and improved outcome in patients with proximal middle cerebral artery occlusion. Stroke 33:1551–1556PubMedCrossRefGoogle Scholar
  18. 18.
    Hacke W, Kaste M, Fieschi C et al (1998) Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet 352(9136):1245–1251PubMedCrossRefGoogle Scholar
  19. 19.
    Furlan A, Higashida R, Wechsler L et al (1999) Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in acute cerebral thromboembolism. JAMA 282:2003–2011PubMedCrossRefGoogle Scholar
  20. 20.
    Penumbra Pivotal Stroke Trial Investigators (2009) The Penumbra pivotal stroke trial: safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. Stroke 40:2761–2768CrossRefGoogle Scholar
  21. 21.
    Bektas H, Wu TC, Kasam M et al (2010) Increased blood–brain barrier permeability on perfusion CT might predict malignant middle cerebral artery infarction. Stroke 41:2539–2544PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Latour LL, Kang DW, Ezzeddine MA et al (2004) Early blood–brain barrier disruption in human focal brain ischemia. Ann Neurol 56:468–477PubMedCrossRefGoogle Scholar
  23. 23.
    Lin Y, Pan Y, Wang M et al (2012) Blood–brain barrier permeability is positively correlated with cerebral microvascular perfusion in the early fluid percussion-injured brain of the rat. Lab Invest 92:1623–1634PubMedCrossRefGoogle Scholar
  24. 24.
    Mayer TE, Schulte-Altedorneburg G, Droste DW, Bruckmann H (2000) Serial CT and MRI of ischaemic cerebral infarcts: frequency and clinical impact of haemorrhagic transformation. Neuroradiology 42:233–239PubMedCrossRefGoogle Scholar
  25. 25.
    Hamann GF, Okada Y, del Zoppo GJ (1996) Hemorrhagic transformation and microvascular integrity during focal cerebral ischemia/reperfusion. J Cereb Blood Flow Metab 16:1373–1378PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2013

Authors and Affiliations

  • D. Morhard
    • 1
  • L. Ertl
    • 1
    • 2
  • W. Gerdsmeier-Petz
    • 1
  • B. Ertl-Wagner
    • 3
  • G. Schulte-Altedorneburg
    • 1
  1. 1.Institute of Diagnostic and Interventional Radiology, Neuroradiology and Nuclear MedicineKlinikum Muenchen-HarlachingMunichGermany
  2. 2.Department of Neuroradiology, Institute of Clinical RadiologyUniversity of MunichMunichGermany
  3. 3.Institute of Clinical RadiologyUniversity of MunichMunichGermany

Personalised recommendations