Letter by Murai et al Regarding Article, "Spot Sign in Acute Intracerebral Hemorrhage in Dynamic T1-Weighted Magnetic Resonance Imaging".

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HomeStrokeVol. 47, No. 5Letter by Murai et al Regarding Article, “Spot Sign in Acute Intracerebral Hemorrhage in Dynamic T1-Weighted Magnetic Resonance Imaging” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Murai et al Regarding Article, “Spot Sign in Acute Intracerebral Hemorrhage in Dynamic T1-Weighted Magnetic Resonance Imaging” Yasuo Murai, MD Yukio Ikeda, MD Akio Morita, MD Yasuo MuraiYasuo Murai Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan Search for more papers by this author Yukio IkedaYukio Ikeda Department of Neurosurgery, Tokyo Medical University, Hachioji Medical Center, Tokyo, Japan Search for more papers by this author Akio MoritaAkio Morita Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan Search for more papers by this author Originally published24 Mar 2016https://doi.org/10.1161/STROKEAHA.116.012812Stroke. 2016;47:e84Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2016: Previous Version 1 To the Editor:We read Schindlbeck et al’s1 article on the predictability of contrast extravasation and hematoma expansion through the use of dynamic contrast-enhanced T1 magnetic resonance imaging (MRI) with great interest.Previously, we explored prediction of hematoma enlargement with observations of contrast fluid leakage using both contrast MRI2 and computed tomographic angiography.3 During our research 18 years ago, we2 used a 0.2-T MRI. However, MRI machines have progressed in the examination time. Schindlbeck et al1 used a 3-T MRI and MRI imaging time has decreased; MRI is becoming an appropriate scan for acute stroke patients with varying neurological findings. Compared with computed tomographic angiography, there is no exposure to radiation in contrast MRI, and the frequency of allergies to contrast fluid is low. It may be a safer, more detailed examination method.Schindlbeck et al1 reported that when MRI spot could be seen, while the frequency of hematoma expansion was not statistically predominant, they correlated with worsening neurological findings. In our study, we2 examined 108 cases and found a correlation between hematoma expansion and contrast medium leakage. Consequently, we2 investigated the form of leakage and the type of contrast site within the hematoma in detail. The presence of large-scale punctate enhancement within hematomas, rather than around hematomas, may be related to so-called angiographic extravasation. As image quality for 0.2-T MRI was poor, we conducted cerebral angiography in the acute stage. We2 also investigated the correlation between extravasation on the angiogram and MRI punctuate sign, which was statistically significant. We chose normal contrast MRI. The difference in our timing, from contrast injection to imaging, from that of the dynamic MRI used by Schindlbeck et al1 may have affected findings. More time passed between injection of contrast medium imaging, allowing sufficient time for extravascular leakage. Normal contrast MRI may also more clearly detect contrast leakage. In another paper4 presenting contrast leakage images from MRI scans of acute cerebral hemorrhage, a larger spot was detected, similar to the punctuate sign we observed. Additionally, opposite the spot in Figure 1A1, in the right Sylvian fissure, there is a cross section of a blood vessel similar to and of the same size as the spot, and in a cross section of the left middle cerebral artery, opposite the spot in Figure 1B, there is a blood vessel cross section larger than the spot. The spots in Figure 1A and 1B may actually capture venous stasis. The higher frequency of spot sign appearance observed by Schindlbeck et al1 seems to support this idea. Although our average time before MRI imaging was lower (3.08±1.28 hours), only 36% (39/108) of our cases2 showed contrast findings in the MRI. Schindlbeck et al1 state that, even for computed tomographic angiography spot sign,3 spot detection rate within 6 hours was ≈30%.3 Consequently, Schindlbeck et al’s1 MRI spots may have included something other than extravasation. If, for example, spots were defined as areas with a diameter of ≥5 mm, the results might differ. We also investigated punctate and linear contrast medium leakages to determine whether they were around hematomas or within them. In the future, this should be considered, as well as possible correlations between these factors and hematoma expansion.We are deeply hopeful that future development of this research will prevent worsening prognoses and acute expansion of cerebral hemorrhage, as well as avoid radiation exposure.Yasuo Murai, MDDepartment of Neurological SurgeryNippon Medical SchoolTokyo, JapanYukio Ikeda, MDDepartment of NeurosurgeryTokyo Medical University, Hachioji Medical CenterTokyo, JapanAkio Morita, MDDepartment of Neurological SurgeryNippon Medical SchoolTokyo, JapanDisclosuresNone.FootnotesStroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 3 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited.