Delayed Postangiographic Contrast Enhancement in Acute Stroke after t-PA Administration Mimicking Intracranial Hemorrhage (P05.217)

Abstract

Objective: To describe neuroimaging features of concurrent angiographic contrast administration in an acute stroke patient post t-PA, and demonstrate the possibility of delayed parenchymal enhancement on computer tomography mimicking intracranial hemorrhage. Recommendations are made to distinguish between these entities with different therapeutic consequences. Background Intracranial hemorrhage is a rare, but feared complication after intravenous t-PA administration. Disruption of the blood-brain-barrier may be responsible for hemorrhagic transformation in many cases. Noncontrast CT is a fast and sensitive method to identify acute bleed. Subacute enhancement in the ischemic region has been described on MRI. On the other hand, delayed contrast enchancement on CT imaging is not well studied, although iodine-based contrast media is frequently used in stroke patients to identify potential concurrent conditions. Design/Methods: This is a case report with relevant neuroimaging review. Results: A 44-year-old female with hypertension, diabetes, hyperlipidemia presented with aphasia and right weakness after cardiac catheterization with contrast administration. She received intravenous t-PA and also required emergent thrombectomy from her lower extremity with heparin administation. Her examination showed flucutating severe aphasia, right facial droop and weakness of the right extremities with some antigravity movements. Initial noncontrast head CT was negative for acute findings, but follow-up CT the next day showed demarcated hypodense area in the left MCA territory with associated hyperdense signal suggestive of large intraparenchymal hemorrhage. Urgent MRI, however, demonstrated no susceptibility artifact or T1 hyperintensity to suggest hematoma. She recovered with residual moderate aphasia and improved strength. She remained on aspirin with medical management of her vascular risk factors. Conclusions: While history, serial neurologic examinations and repeat CT play an important role in differentiating between intracranial hemorrhage and delayed postangiographic contrast enhancement, these may be difficult to interpret in patients with mutliple acute morbidities. Obtaining urgent MRI imaging was able to reliably exclude hemorrhage and guide medical therapy in our patient. Disclosure: Dr. Toth has nothing to disclose. Dr. Beary has nothing to disclose. Dr. Samuel has nothing to disclose. Dr. Uchino has nothing to disclose. Dr. Hussain has nothing to disclose.