Abstract
Background and Purpose: We aimed to determine whether dual-energy CT (DECT) follow-up can differentiate contrast staining (CS) from intracranial hemorrhage (ICH) in stroke patients treated with intravenous thrombolysis (IVT), who had undergone acute stroke imaging using CT angiography (CTA), and CT perfusion (CTP).Materials and Methods: Between November 2012 and January 2018, 168 patients at our comprehensive stroke center underwent DECT follow-up within 36 h after IVT and acute CTA with or without CTP but did not receive intra-arterial imaging or treatment. Two independent readers evaluated plain monochromatic CT (pCT) alone and compared this with a second reading of a combined DECT approach using pCT and water- and iodine-weighted images, establishing and grading the ICH diagnosis, per Heidelberg and Safe Implementation of Treatments in Stroke Monitoring Study (SITS-MOST) classifications.Results: On pCT alone within 36 h, 31/168 (18.5%) patients had findings diagnosed as ICH. Using combined DECT (cDECT) changed ICH diagnosis to “CS only” in 3/168 (1.8%) patients, constituting 3/31 (9.7%) of cases with initially pCT-diagnosed ICH. These three cases had pCT diagnoses of one SAH, one minor, and one more extensive petechial hemorrhage (hemorrhagic infarction types 1 and 2), respectively. pCT alone had a 100% sensitivity, 98% specificity, 90% positive predictive value (PPV), 100% negative predictive value (NPV), and 98% accuracy for any ICH, compared to the cDECT. Inter-reader agreement for ICH classification using pCT compared to DECT was weighted kappa 0.92 (95% CI 0.87–0.98) vs. 0.91 (0.85–0.95).Conclusion: Compared to pCT, DECT within 36 h after IV thrombolysis for acute ischemic stroke, changes the radiological diagnosis of post-treatment ICH to “CS only” in a small proportion of patients. Studies are warranted of whether the altered radiological reports have an impact on patient management, for example initiation timing of antithrombotic secondary prevention.
Highlights
The 2018 American Heart Association (AHA)/American Stroke Association (ASA) acute ischemic stroke (AIS) guidelines recommend a follow-up CT or MRI scan at 24 h after intravenous thrombolysis (IVT), prior to initiation of secondary preventive treatment with antithrombotic agents [1].Previous dual-energy CT (DECT) studies have focused on imaging after intra-arterial endovascular therapy (EVT), contrast staining (CS) concealing infarcts, the mimicking of hemorrhagic events in 10–85% depending on the time window, prognostication of infarct size, or a later hemorrhage depending on the amount of immediate iodine leakage [2,3,4,5,6,7]
A total of 219 screened patients with AIS were treated with IVT, had IV contrast CT examination at baseline (CTA and/or CT perfusion (CTP)), and had no endovascular imaging or treatment
Of the remaining 172 with DECT exams, 4/172 (2.3%) cases were excluded because >36 h has passed between IVT initiation and DECT
Summary
Previous dual-energy CT (DECT) studies have focused on imaging after intra-arterial endovascular therapy (EVT), contrast staining (CS) concealing infarcts, the mimicking of hemorrhagic events in 10–85% depending on the time window, prognostication of infarct size, or a later hemorrhage depending on the amount of immediate iodine leakage [2,3,4,5,6,7]. The added value and aim are to understand whether there is CS or not in the brain that may mimic hemorrhagic events on a routine 24-h follow-up after IVT in patients examined with CTA and/or CT perfusion (CTP), without additional EVT. We aimed to determine whether dual-energy CT (DECT) follow-up can differentiate contrast staining (CS) from intracranial hemorrhage (ICH) in stroke patients treated with intravenous thrombolysis (IVT), who had undergone acute stroke imaging using CT angiography (CTA), and CT perfusion (CTP)
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