Acta Neurol Belg DOI 10.1007/s13760-015-0481-5
LETTER TO THE EDITOR
Contrast extravasation mimics cerebral hemorrhage in acute ischemic stroke after Solitaire FR clot retrieval and intraarterial thrombolysis: a case report Ying Mao1 • Guang-xian Nan1 • Li Zhang1 • Yu-jing Huang1
Received: 23 March 2015 / Accepted: 20 April 2015 Ó Belgian Neurological Society 2015
Introduction
Case report
Thrombolysis with intravenous recombinant tPA has been established as a treatment strategy for patients with acute ischemic stroke. However, the effects of intravenous thrombolysis on the occlusion of intracranial large arteries are limited. Moreover, tPA requires a large dose of the thrombolytic agent, which may be associated with increased risk of complications such as hemorrhagic transformation. These issues significantly limit the use of intravenous thrombolytic therapy in the clinic. Currently, mechanical clot retrieval and intraarterial thrombolysis are increasingly used in many large institutions for treatment of acute ischemic stroke, as an alternative to intravenous thrombolytic therapy in the clinic, which is believed to improve the rate of vascular recanalization and patient outcome. Current shortcomings for mechanical clot retrieval in stroke patients include the delayed initial treatment of mechanical clot retrieval and limited application of effective Solitaire stent embolus removal system in the clinic. Here we report a hyperdense lesion mimicking cerebral hemorrhage on a nonenhanced CT image after mechanical clot retrieval Solitaire stent embolus removal system and intraarterial thrombolysis early following acute ischemic stroke with occlusion of intracranial large arteries.
A 64-year-old female patient presented with sudden disturbance of speech and right-sided limb weakness for 2 h. Neurological examination on admission showed drowsiness with horizontal gaze palsy, completely mixed aphasia, significantly reduced muscle power of the right-sided limbs to grade 0–I, and Babinski’s sign on the right. NIHSS score was 19. Cranial CT scans on admission did not show abnormal signs (Fig. 1a). The patient was admitted to our hospital. After excluding contraindications, emergency digital subtraction angiography (DSA) of the carotid artery was performed, 150 min after stroke onset. The DSA indicated moderate stenosis in the bifurcation of the left common carotid artery (Fig. 1b) and distal occlusion of the left internal carotid artery (ICA) (Fig. 1c). With a guidewire, a 6F guiding catheter was placed gently and cautiously near the anterior petrous segment of the left ICA. Then we navigated a Rebar 0.027’’ micro catheter through the occlusive segment of the ICA with the help of a Traxcess 14EX micro guidewire that was placed at the M2 segment of the middle cerebral artery (MCA). Further angiography through the micro catheter showed the distal branches of the left MCA (Fig. 1d). After the withdrawal of the micro guidewire, a 4 mm 9 20 mm Solitaire FR stent was placed along the micro catheter and then released. Five minutes after the stent release, the stent and micro catheter were pulled back and simultaneously the blood was sucked from the guiding catheter under negative pressure with a 20-mL syringe (Fig. 1e). Further angiography showed restoration of the left ICA, supplying the distribution of the MCA via the meningeal artery. The M1 segment of the left MCA was restored, which was associated with well-defined deep perforating
& Guang-xian Nan [email protected] 1
Department of Neurology, China-Japan Union Hospital of Jilin University, No. 126 Xian Tai Street, Changchun 130021, China
123
Acta Neurol Belg
Fig. 1 Preoperative, intraoperative, and postoperative radiological images. a Preoperative CT. b Cerebral angiography showed the left carotid artery bifurcation filled with plaque. c An occlusion at the end of the left internal carotid artery. d Angiography using the micro guidewire through the occlusive segment. e Solitaire stent releasing. f Angiography after Solitaire stent embolectomy. g CT immediately
after vascular recanalization, with a high-density lesion in the left basal ganglia. h CT image on the next day. The high-density area disappeared and a lamellar shadow appeared. (i–l) Cranial MRI. A new infarction appeared in the left basal ganglion area and insula. m Cranial MRA shows revascularization of the left ICA, anterior cerebral artery, and partial branches of the MCA
branches and the furcation of the inferior trunk. However, the superior trunk could not be seen on the angiogram (Fig. 1f). Thus, intraarterial thrombolysis using recombinant tissue plasminogen activator (tPA; 10 mg, 1 mg/min) was performed. The superior trunk remained absent on another angiogram. After the neurointerventional procedures, gaze palsy resolved and the patient recovered consciousness. The NIHSS score was then 13. However, a nonenhanced CT scan performed immediately upon completion of the intervention showed a hyperdense lesion in the left basal ganglia (Fig. 1g). A CT scan performed on the second day after neurointervention indicated that the hyperdense lesion in the left basal ganglia had disappeared and left a patchy fuzzy low-density shadow (Fig. 1h). Further magnetic resonance imaging (MRI) confirmed the appearance of a new infarction in the left basal ganglion area and insula (Fig. 1i–l), and a magnetic resonance angiogram (MRA) showed revascularization of the left ICA, anterior cerebral artery, and partial branches of the MCA (Fig. 1m). Thus the previous hyperdense lesion in the left basal ganglia was considered a contrast extravasation in the new infarct area.
Two weeks later, the NIHSS score had recovered to 8. After a follow-up of 90 days, the NIHSS score was 5 and the modified ranking score was 2.
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Discussion It is well known that hemorrhagic transformation with deterioration of neurological symptoms is the major complication of endovascular procedures and intraarterial thrombolysis. Nakano et al. [1] thought that the rapid disappearance of a high-density lesion was key to a diagnosis of contrast extravasation—most contrast extravasation has no mass effect or edema, and a CT scan will show that the area of high density disappears after 24 h. Hemorrhagic transformation, such as hematoma formation, may cause a mass effect, and the high density remained in the cranial CT after 24 h. According to Mericle et al. [2], a maximum CT value \90 HU was a reliable sign of contrast agent enhancement, and the density of the stain was related to the amount of contrast agent used in surgery. These findings are consistent with our case, which indicated that a
Acta Neurol Belg
hyperdense lesion in the left basal ganglia had no mass effect and had disappeared in the repeated CT on the second day after endovascular procedures. The underlying pathophysiology of contrast extravasation is the leakage of contrast medium from vessels into extracellular spaces due to the increased permeability of the blood–brain barrier. Much evidence has indicated that cerebral infarction can significantly increase permeability of the blood–brain barrier via multiple mechanisms [3]. In conclusion, we should be aware that hyperdense lesions on CT scans obtained after endovascular procedures are usually not associated with hemorrhagic complications, and contrast extravasation needs to be considered in the differential diagnosis. Conflict of interest interest.
We declare that there are no conflicts of
Informed consent from the patient.
Informed consent for publication was obtained
References 1. Nakano S, Iseda T, Kawano H, Yoneyama T, Ikeda T, Wakisaka S (2001) Parenchymal hyperdensity on computed tomography after intra-arterial reperfusion therapy for acute middle cerebral artery occlusion: incidence and clinical significance. Stroke 32(9):2042– 2048 2. Mericle RA, Lopes DK, Fronckowiak MD, Wakhloo AK, Guterman LR, Hopkins LN (2000) A grading scale to predict outcomes after intra-arterial thrombolysis for stroke complicated by contrast extravasation. Neurosurgery 46(6):1307–1314; discussion 1314–1315 3. Khatri R, McKinney AM, Swenson B, Janardhan V (2012) Bloodbrain barrier, reperfusion injury, and hemorrhagic transformation in acute ischemic stroke. Neurology 79(13 Suppl 1):S52–S57. doi:10.1212/WNL.0b013e3182697e70
Ethical standard We declare that we acted in accordance with the ethical standards laid down in the 1964 declaration of Helsinki.
123
LETTER TO THE EDITOR
Contrast extravasation mimics cerebral hemorrhage in acute ischemic stroke after Solitaire FR clot retrieval and intraarterial thrombolysis: a case report Ying Mao1 • Guang-xian Nan1 • Li Zhang1 • Yu-jing Huang1
Received: 23 March 2015 / Accepted: 20 April 2015 Ó Belgian Neurological Society 2015
Introduction
Case report
Thrombolysis with intravenous recombinant tPA has been established as a treatment strategy for patients with acute ischemic stroke. However, the effects of intravenous thrombolysis on the occlusion of intracranial large arteries are limited. Moreover, tPA requires a large dose of the thrombolytic agent, which may be associated with increased risk of complications such as hemorrhagic transformation. These issues significantly limit the use of intravenous thrombolytic therapy in the clinic. Currently, mechanical clot retrieval and intraarterial thrombolysis are increasingly used in many large institutions for treatment of acute ischemic stroke, as an alternative to intravenous thrombolytic therapy in the clinic, which is believed to improve the rate of vascular recanalization and patient outcome. Current shortcomings for mechanical clot retrieval in stroke patients include the delayed initial treatment of mechanical clot retrieval and limited application of effective Solitaire stent embolus removal system in the clinic. Here we report a hyperdense lesion mimicking cerebral hemorrhage on a nonenhanced CT image after mechanical clot retrieval Solitaire stent embolus removal system and intraarterial thrombolysis early following acute ischemic stroke with occlusion of intracranial large arteries.
A 64-year-old female patient presented with sudden disturbance of speech and right-sided limb weakness for 2 h. Neurological examination on admission showed drowsiness with horizontal gaze palsy, completely mixed aphasia, significantly reduced muscle power of the right-sided limbs to grade 0–I, and Babinski’s sign on the right. NIHSS score was 19. Cranial CT scans on admission did not show abnormal signs (Fig. 1a). The patient was admitted to our hospital. After excluding contraindications, emergency digital subtraction angiography (DSA) of the carotid artery was performed, 150 min after stroke onset. The DSA indicated moderate stenosis in the bifurcation of the left common carotid artery (Fig. 1b) and distal occlusion of the left internal carotid artery (ICA) (Fig. 1c). With a guidewire, a 6F guiding catheter was placed gently and cautiously near the anterior petrous segment of the left ICA. Then we navigated a Rebar 0.027’’ micro catheter through the occlusive segment of the ICA with the help of a Traxcess 14EX micro guidewire that was placed at the M2 segment of the middle cerebral artery (MCA). Further angiography through the micro catheter showed the distal branches of the left MCA (Fig. 1d). After the withdrawal of the micro guidewire, a 4 mm 9 20 mm Solitaire FR stent was placed along the micro catheter and then released. Five minutes after the stent release, the stent and micro catheter were pulled back and simultaneously the blood was sucked from the guiding catheter under negative pressure with a 20-mL syringe (Fig. 1e). Further angiography showed restoration of the left ICA, supplying the distribution of the MCA via the meningeal artery. The M1 segment of the left MCA was restored, which was associated with well-defined deep perforating
& Guang-xian Nan [email protected] 1
Department of Neurology, China-Japan Union Hospital of Jilin University, No. 126 Xian Tai Street, Changchun 130021, China
123
Acta Neurol Belg
Fig. 1 Preoperative, intraoperative, and postoperative radiological images. a Preoperative CT. b Cerebral angiography showed the left carotid artery bifurcation filled with plaque. c An occlusion at the end of the left internal carotid artery. d Angiography using the micro guidewire through the occlusive segment. e Solitaire stent releasing. f Angiography after Solitaire stent embolectomy. g CT immediately
after vascular recanalization, with a high-density lesion in the left basal ganglia. h CT image on the next day. The high-density area disappeared and a lamellar shadow appeared. (i–l) Cranial MRI. A new infarction appeared in the left basal ganglion area and insula. m Cranial MRA shows revascularization of the left ICA, anterior cerebral artery, and partial branches of the MCA
branches and the furcation of the inferior trunk. However, the superior trunk could not be seen on the angiogram (Fig. 1f). Thus, intraarterial thrombolysis using recombinant tissue plasminogen activator (tPA; 10 mg, 1 mg/min) was performed. The superior trunk remained absent on another angiogram. After the neurointerventional procedures, gaze palsy resolved and the patient recovered consciousness. The NIHSS score was then 13. However, a nonenhanced CT scan performed immediately upon completion of the intervention showed a hyperdense lesion in the left basal ganglia (Fig. 1g). A CT scan performed on the second day after neurointervention indicated that the hyperdense lesion in the left basal ganglia had disappeared and left a patchy fuzzy low-density shadow (Fig. 1h). Further magnetic resonance imaging (MRI) confirmed the appearance of a new infarction in the left basal ganglion area and insula (Fig. 1i–l), and a magnetic resonance angiogram (MRA) showed revascularization of the left ICA, anterior cerebral artery, and partial branches of the MCA (Fig. 1m). Thus the previous hyperdense lesion in the left basal ganglia was considered a contrast extravasation in the new infarct area.
Two weeks later, the NIHSS score had recovered to 8. After a follow-up of 90 days, the NIHSS score was 5 and the modified ranking score was 2.
123
Discussion It is well known that hemorrhagic transformation with deterioration of neurological symptoms is the major complication of endovascular procedures and intraarterial thrombolysis. Nakano et al. [1] thought that the rapid disappearance of a high-density lesion was key to a diagnosis of contrast extravasation—most contrast extravasation has no mass effect or edema, and a CT scan will show that the area of high density disappears after 24 h. Hemorrhagic transformation, such as hematoma formation, may cause a mass effect, and the high density remained in the cranial CT after 24 h. According to Mericle et al. [2], a maximum CT value \90 HU was a reliable sign of contrast agent enhancement, and the density of the stain was related to the amount of contrast agent used in surgery. These findings are consistent with our case, which indicated that a
Acta Neurol Belg
hyperdense lesion in the left basal ganglia had no mass effect and had disappeared in the repeated CT on the second day after endovascular procedures. The underlying pathophysiology of contrast extravasation is the leakage of contrast medium from vessels into extracellular spaces due to the increased permeability of the blood–brain barrier. Much evidence has indicated that cerebral infarction can significantly increase permeability of the blood–brain barrier via multiple mechanisms [3]. In conclusion, we should be aware that hyperdense lesions on CT scans obtained after endovascular procedures are usually not associated with hemorrhagic complications, and contrast extravasation needs to be considered in the differential diagnosis. Conflict of interest interest.
We declare that there are no conflicts of
Informed consent from the patient.
Informed consent for publication was obtained
References 1. Nakano S, Iseda T, Kawano H, Yoneyama T, Ikeda T, Wakisaka S (2001) Parenchymal hyperdensity on computed tomography after intra-arterial reperfusion therapy for acute middle cerebral artery occlusion: incidence and clinical significance. Stroke 32(9):2042– 2048 2. Mericle RA, Lopes DK, Fronckowiak MD, Wakhloo AK, Guterman LR, Hopkins LN (2000) A grading scale to predict outcomes after intra-arterial thrombolysis for stroke complicated by contrast extravasation. Neurosurgery 46(6):1307–1314; discussion 1314–1315 3. Khatri R, McKinney AM, Swenson B, Janardhan V (2012) Bloodbrain barrier, reperfusion injury, and hemorrhagic transformation in acute ischemic stroke. Neurology 79(13 Suppl 1):S52–S57. doi:10.1212/WNL.0b013e3182697e70
Ethical standard We declare that we acted in accordance with the ethical standards laid down in the 1964 declaration of Helsinki.
123
