Hyper-attenuating brain lesions on CT after ischemic stroke and thrombectomy are associated with final brain infarction

Abstract

Purpose

Hyper-attenuating lesions, or contrast staining, on a non-contrast brain computed tomography (NCCT) scan have been investigated as a predictor for hemorrhagic transformation after endovascular treatment of acute ischemic stroke (AIS). However, the association of hyper-attenuating lesions and final ischemic areas are poorly investigated in this setting. The aim of the present study was to assess correlations between hyper-attenuating lesions and final brain infarcted areas after thrombectomy for AIS.

Methods

Data from patients with AIS of the anterior circulation who underwent endovascular treatment were retrospectively assessed. Images of the brain NCCT scans were analyzed in the first hours and late after treatment. The hyper-attenuating areas were compared to the final ischemic areas using the Alberta Stroke Program Early CT Score (ASPECTS).

Results

Seventy-one of the 123 patients (65.13%) treated were included. The association between the hyper-attenuating region in the post-thrombectomy CT scan and final brain ischemic area were sensitivity (58.3% to 96.9%), specificity (42.9% to 95.6%), positive predictive values (71.4% to 97.7%), negative predictive values (53.8% to 79.5%), and accuracy values (68% to 91%). The highest sensitivity values were found for the lentiform (96.9%) and caudate nuclei (80.4%) and for the internal capsule (87.5%), and the lowest values were found for the M1 (58.3%) and M6 (66.7%) cortices.

Conclusions

Hyper-attenuating lesions on head NCCT scans performed after endovascular treatment of AIS may predict final brain infarcted areas. The prediction appears to be higher in the deep brain regions compared with the cortical regions.

Keywords

Acute stroke endovascular recanalization computed tomography mechanical thrombectomy contrast enhancement

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References

Yoon

Seo

Kim

et al.

Contrast enhancement and contrast extravasation on computed tomography after intraarterial thrombolysis in patients with acute ischemic stroke. Stroke 2004; 35: 876–881.

Parrilla

García-Villalba

Espinosa de Rueda

et al.

Hemorrhage/contrast staining areas after mechanical intra-arterial thrombectomy in acute ischemic stroke: Imaging findings and clinical significance. AJNR Am J Neuroradiol 2012; 33: 1791–1796.

Kim

Park

Lee

et al.

The cortical contrast accumulation from brain computed tomography after endovascular treatment predicts symptomatic hemorrhage. Eur J Neurol 2015; 22: 1453–1458.

Yoon

Jung

et al.

Subarachnoid hemorrhage in a multimodal approach heavily weighted toward mechanical thrombectomy with solitaire stent in acute stroke. Stroke 2013; 44: 414–419.

Khatri

McKinney

Swenson

et al.

Blood-brain barrier, reperfusion injury, and hemorrhagic transformation in acute ischemic stroke. Neurology 2012; 79(13 Suppl 1): S52–S57.

Desilles

Rouchaud

Labreuche

et al.

Blood-brain barrier disruption is associated with increased mortality after endovascular therapy. Neurology 2013; 80: 844–851.

Payabvash

Qureshi

Khan

et al.

Differentiating intraparenchymal hemorrhage from contrast extravasation on post-procedural noncontrast CT scan in acute ischemic stroke patients undergoing endovascular treatment. Neuroradiology 2014; 56: 737–744.

Jang

Lee

Kim

et al.

The fate of high-density lesions on the non-contrast CT obtained immediately after intra-arterial thrombolysis in ischemic stroke patients. Korean J Radiol 2006; 7: 221–228.

Payabvash

Qureshi

Taleb

et al.

Middle cerebral artery residual contrast stagnation on noncontrast CT scan following endovascular treatment in acute ischemic stroke patients. J Neuroimaging 2015; 25: 946–951.

10.

Phan

Yoo

Hirsch

et al.

Differentiation of hemorrhage from iodinated contrast in different intracranial compartments using dual-energy head CT. AJNR Am J Neuroradiol 2012; 33: 1088–1094.

11.

Tijssen

Hofman

Stadler

et al.

The role of dual energy CT in differentiating between brain haemorrhage and contrast medium after mechanical revascularisation in acute ischaemic stroke. Eur Radiol 2014; 24: 834–840.

12.

Gupta

Phan

Leidecker

et al.

Evaluation of dual-energy CT for differentiating intracerebral hemorrhage from iodinated contrast material staining. Radiology 2010; 257: 205–211.

13.

Nakano

Iseda

Kawano

et al.

Parenchymal hyperdensity on computed tomography after intra-arterial reperfusion therapy for acute middle cerebral artery occlusion: Incidence and clinical significance. Stroke 2001; 32: 2042–2048.

14.

Payabvash

Khan

Qureshi

et al.

Detection of intraparenchymal hemorrhage after endovascular therapy in patients with acute ischemic stroke using immediate postprocedural flat-panel computed tomography scan. J Neuroimaging 2016; 26: 213–218.

15.

Antonucci

Mocco

Bennett

. New insight into transient contrast enhancement on computed tomography after endovascular treatment of stroke. Interv Neuroradiol 2012; 18: 303–308.

16.

Ghobrial

Nair

Dalyai

et al.

Contrast stasis on noncontrast computed tomography as a predictor of stroke post-thrombolysis. Neurosurg Focus 2011; 30: E13.

17.

Nikoubashman

Reich

Gindullis

et al.

Clinical significance of post-interventional cerebral hyperdensities after endovascular mechanical thrombectomy in acute ischaemic stroke. Neuroradiology 2014; 56: 41–50.

18.

Song

Ahn

Rhee

et al.

Extent of contrast enhancement on non-enhanced computed tomography after intra-arterial thrombectomy for acute infarction on anterior circulation: As a predictive value for malignant brain edema. J Korean Neurosurg Soc 2015; 58: 321–327.

19.

Lummel

Schulte-Altedorneburg

Bernau

et al.

Hyperattenuated intracerebral lesions after mechanical recanalization in acute stroke. AJNR Am J Neuroradiol 2014; 35: 345–351.

20.

Pexman

Barber

Hill

et al.

Use of the Alberta Stroke Program Early CT Score (ASPECTS) for assessing CT scans in patients with acute stroke. AJNR Am J Neuroradiol 2001; 22: 1534–1542.

21.

Lucena

Castro-Afonso

Monsignore

et al.

Carotid artery stenting in the context of endovascular treatment of acute ischemic stroke. Arq Neuropsiquiatr 2016; 74: 212–218.

22.

Larrue

von Kummer

Müller

et al.

Risk factors for severe hemorrhagic transformation in ischemic stroke patients treated with recombinant tissue plasminogen activator: A secondary analysis of the European-Australasian Acute Stroke Study (ECASS II). Stroke 2001; 32: 438–441.

23.

Huang

Kim

Atochin

et al.

Cerebral blood volume affects blood-brain barrier integrity in an acute transient stroke model. J Cereb Blood Flow Metab 2013; 33: 898–905.

24.

Ostwaldt

Rozanski

Schmidt

et al.

Early time course of FLAIR signal intensity differs between acute ischemic stroke patients with and without hyperintense acute reperfusion marker. Cerebrovasc Dis 2014; 37: 141–146.

25.

Hom

Dankbaar

Soares

et al.

Blood-brain barrier permeability assessed by perfusion CT predicts symptomatic hemorrhagic transformation and malignant edema in acute ischemic stroke. AJNR Am J Neuroradiol 2011; 32: 41–48.

26.

Gariani

Cuvinciuc

Courvoisier

et al.

Diagnosis of acute ischemia using dual energy CT after mechanical thrombectomy. J Neurointerv Surg 2016; 8: 996–1000.

27.

Pexman

Barber

Hill

et al.

Use of the Alberta Stroke Program Early CT Score (ASPECTS) for assessing CT scans in patients with acute stroke. AJNR Am J Neuroradiol 2001; 22: 1534–1542.

28.

Liebeskind

Jahan

Nogueira

et al.

Serial Alberta Stroke Program early CT score from baseline to 24 hours in Solitaire Flow Restoration with the Intention for Thrombectomy study: A novel surrogate end point for revascularization in acute stroke. Stroke 2014; 45: 723–727.

29.

Kumral

Evyapan

Balkir

. Acute caudate vascular lesions. Stroke 1999; 30: 100–108.

30.

Wahlgren

Ahmed

Dávalos

et al.

Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): An observational study. Lancet 2007; 369: 275–282.

31.

Lambrinos

Schaink

Dhalla

et al.

Mechanical thrombectomy in acute ischemic stroke: A systematic review. Can J Neurol Sci 2016; 43: 455–460.