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Differentiating contrast staining after acute ischemic stroke from hemorrhagic transformation during emergency evaluation
YAJEM-55814; No of Pages 2 American Journal of Emergency Medicine xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
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Case Report
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Differentiating contrast staining after acute ischemic stroke from hemorrhagic transformation during emergency evaluation
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Brain computed tomography (CT) is a powerful imaging modality that can be used to rapidly establish a stroke diagnosis in patients who present with neurologic deficits in emergency departments (EDs). When interpreting a brain CT image, a hyperdense lesion usually indicates a hemorrhage. A rare condition, acute cerebral infarction with contrast staining (CS), develops in some patients who undergo procedures that require the use of contrast agents; such procedures include coronary angiographies and carotid or peripheral vascular angiographies [1]. Contrast staining has most often been reported in acute ischemic stroke (AIS) patients who are receiving thrombolytic therapy [2–5]; however, CS has rarely been described in AIS patients who are undergoing conservative medical treatment, have chronic kidney disease, and have recently received a contrast agent. We report the case of a 75-year-old man with a medical history of hypertension, diabetes mellitus, and end-stage renal disease who was on hemodialysis and underwent a percutaneous coronary intervention (PCI) for stable ischemic heart disease 2 days before arriving at our ED. The complex technique of rotational atherectomy was performed during the PCI procedure to alleviate severe calcification of the coronary arteries; he was then discharged uneventfully. Unfortunately, when he
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arrived in our ED, he had been unable to hold chopsticks for the previous 10 hours. Upon arrival, his blood pressure was 186/104 mm Hg, his heart rate was 96 beats per minute, and his respiratory rate was 22 breaths per minute. A physical examination indicated that the muscle power score of his right side extremities was a 2, and he had a National Institutes of Health Stroke Scale score of 6. A brain CT scan demonstrated a sulcal or cortical hyperdense lesion in the left frontal lobe (Fig. 1). As this is an unusual area for subarachnoid or cerebral hemorrhaging, an urgent brain magnetic resonance imaging (MRI) scan was performed to confirm the diagnosis. Diffusion-weighted imaging revealed a highintensity signal in the left precentral gyrus (Fig. 2A, white arrow) with a corresponding low-intensity signal revealed via apparent diffusion coefficient imaging (Fig. 2B, white arrow), which was consistent with acute cerebral infarction. Contrast medium administered during the PCI procedure 2 days prior had leaked from the damaged blood-brain barrier and resulted in CS, as shown by the brain CT scan of this patient with end-stage renal disease. If physicians misinterpret CS as a hemorrhagic transformation (HT), they might incorrectly decide to discontinue dual antiplatelet treatment, which could cause serious adverse effects such as subacute thrombosis or death in patients such as ours, who had just undergone the implantation of stents 2 days prior. The interruption of dual antiplatelet treatment within 7 days of starting the treatment has been associated with a notable increase in cardiac death [6]. The therapeutic goal of blood pressure control is also very different for AIS with CS than it is for HT. Therefore, establishing an accurate diagnosis was vital for our patient, who had neurologic deficits and was recently administered contrast. Contrast staining on brain CT scans was most often reported in AIS patients receiving thrombolytic therapy and being administered contrast; the incidence of CS was 31% to 60% among these patients [2–5]. In patients receiving intraarterial tissue plasminogen activator (IAtPA), approximately 90% of patients with CS were observed to develop HF in follow-up CT scans within 24 hours, indicating that IAtPA increased the risk of HT in these patients [2]. Notably, there was a conflicting result from another study that did not show HF in follow-up CT scans within 48 to 72 hours in those receiving mechanical thrombectomy rather than IAtPA [3]. The risk of HT in our patient, who was not receiving thrombolytic therapy, should have been very low, similar to patients not receiving IAtPA. Differentiating CS from HT after AIS was dependent on the presence of anatomical boundaries and on the absence of a significant mass effect and surrounding edema [5]. Hounsfield unit values of more than 90 U, as an upper threshold, were thought to be a diagnostic indicator of CS, whereas a Hounsfield unit value of 40 U was used as a lower diagnostic threshold [5,7]. Based on the above criteria for the diagnosis of CS, the incidence of HT remained as high as 6% [1,2]. Using dual-energy CT to accurately differentiate hemorrhage from CS had
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Abstract A hyperdense lesion observed in a computed tomographic (CT) image of the brain is usually suspected to be a hemorrhage during an emergency evaluation. Other rare differential diagnoses include contrast-induced encephalopathy (CIN) and acute cerebral infarction with contrast staining (CS). Recent contrast administration is a common risk factor for both CIN and CS. The former has been associated with favorable neurologic outcomes, whereas CS might have complications, such as hemorrhagic transformation (HT). Contrast staining on brain CT scans was most often reported in acute ischemic stroke patients receiving thrombolytic therapy and being administered contrast; the incidence of CS was 31% to 60% among these patients. Differentiating CS from HT after acute ischemic stroke was dependent on the presence of anatomical boundaries and on the absence of a significant mass effect and surrounding edema. The Hounsfield unit scale was also used to differentiate contrast or hemorrhage alone from mixed contrast and hemorrhage on brain CT scans. Clarifying the properties of a hyperdense lesion on a brain CT scan is essential because the therapeutic strategies for treating CS vs HT are completely different, including differences in the therapeutic goal of controlling blood pressure and in the use of antiplatelet agents. We report a rare condition in which CS developed in an elderly patient because of end-stage renal disease, but the patient was not receiving thrombolytic therapy. An urgent brain magnetic resonance imaging scan was used to confirm the diagnosis of CS, which further guided the treatment of this patient.
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0735-6757/© 2016 Published by Elsevier Inc.
Please cite this article as: Ho S-K, et al, Differentiating contrast staining after acute ischemic stroke from hemorrhagic transformation during emergency evaluation, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.035
51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 Q2 83 84 85 86 87 88 89 90 91 92 93 94 95 96
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S-K. Ho et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
Yen-Jun Lai 116 Neuroradiology, Diagnostic and Interventional Department of Medical 117 Imaging, Far Eastern Memorial Hospital, New Taipei City, Taiwan 118 119
Tzu-Chiao Lin 120 Division of Cardiology, Department of Internal Medicine, Tri-Service 121 General Hospital, National Defense Medical Center, Taipei, Taiwan 122
105 106 107 108 109 110 111 112 113 114
Sing-Kong Ho Cardiology Division of Cardiovascular Medical Center Far Eastern Memorial Hospital, New Taipei City, Taiwan Jen-Kuang Lee Division of Cardiology, Department of Internal Medicine National Taiwan University Hospital, Taipei, Taiwan
129 130 131 132 133
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[1] Kocabay G, Karabay CY, Kalayci A, Akgun T, Guler A, Oduncu V, et al. Contrast-induced neurotoxicity after coronary angiography. Herz 2014;39(4):522–7. [2] Nakano S, Iseda T, Yoneyama T, Wakisaka S. Early CT signs in patients with acute middle cerebral artery occlusion: incidence of contrast staining and haemorrhagic transformations after intra-arterial reperfusion therapy. Clin Radiol 2006;61(2):156–62. [3] Parrilla G, Garcia-Villalba B, Espinosa de Rueda M, Zamarro J, Carrion E, HernandezFernandez F, et al. Hemorrhage/contrast staining areas after mechanical intraarterial thrombectomy in acute ischemic stroke: imaging findings and clinical significance. AJNR Am J Neuroradiol 2012;33(9):1791–6. [4] Phan CM, Yoo AJ, Hirsch JA, Nogueira RG, Gupta R. Differentiation of hemorrhage from iodinated contrast in different intracranial compartments using dual-energy head CT. AJNR Am J Neuroradiol 2012;33(6):1088–94. [5] Amans MR, Cooke DL, Vella M, Dowd CF, Halbach VV, Higashida RT, et al. Contrast staining on CT after DSA in ischemic stroke patients progresses to infarction and rarely hemorrhages. Interv Neuroradiol 2014;20(1):106–15. [6] Mehran R, Baber U, Steg PG, Ariti C, Weisz G, Witzenbichler B, et al. Cessation of dual antiplatelet treatment and cardiac events after percutaneous coronary intervention (PARIS): 2 year results from a prospective observational study. Lancet. 382(9906): 1714–22. [7] Mericle RA, Lopes DK, Fronckowiak MD, Wakhloo AK, Guterman LR, Hopkins LN. A grading scale to predict outcomes after intra-arterial thrombolysis for stroke complicated by contrast extravasation. Neurosurgery 2000;46(6):1307–14. [8] Schindlbeck KA, Santaella A, Galinovic I, Krause T, Rocco A, Nolte CH, et al. Spot sign in acute intracerebral hemorrhage in dynamic T1-weighted magnetic resonance imaging. Stroke 2016;47(2):417–23.
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References
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the advantages of 100% sensitivity and 92.8% specificity, but calcification was a major limitation [4]. Although time consuming and difficult to use in patients who have a critical illness, MRI enables the detection of a hemorrhage with more accuracy than a CT, and hemorrhages are associated with poor clinical outcomes [8]. It is essential to establish accurate diagnoses in patients who present with neurologic deficits and have recently been exposed to a contrast agent, especially patients with chronic kidney disease. Because a brain CT may not result in a definite diagnosis, an urgent MRI is necessary to distinguish CS from HT after AIS.
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http://dx.doi.org/10.1016/j.ajem.2016.05.035
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Fig. 1. A brain CT scan revealed a hyperdense sulcal or cortical lesion in the left frontal lobe (white arrow).
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Cheng-Wei Liu Division of Cardiology, Department of Internal Medicine Tri-Service General Hospital, Songshan Branch National Defense Medical Center Taipei, Taiwan Corresponding author at: Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, Songshan Branch National Defense Medical Center Taipei, No.131, Jiankang Rd Songshan District, Taipei City, 105, Taiwan (ROC) Tel.: +886 910682383; fax: +886 2 28837372 E-mail address: [email protected]
Fig. 2. A brain MRI scan revealed a high-intensity signal in the left precentral gyrus using diffusion-weighted imaging (A, white arrow) with a corresponding low-intensity signal shown via apparent diffusion coefficient imaging (B, white arrow).
Please cite this article as: Ho S-K, et al, Differentiating contrast staining after acute ischemic stroke from hemorrhagic transformation during emergency evaluation, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.035
137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 Q3 156 157 158 159 160 161
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
1
Case Report
4
Differentiating contrast staining after acute ischemic stroke from hemorrhagic transformation during emergency evaluation
O
3
5
19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Brain computed tomography (CT) is a powerful imaging modality that can be used to rapidly establish a stroke diagnosis in patients who present with neurologic deficits in emergency departments (EDs). When interpreting a brain CT image, a hyperdense lesion usually indicates a hemorrhage. A rare condition, acute cerebral infarction with contrast staining (CS), develops in some patients who undergo procedures that require the use of contrast agents; such procedures include coronary angiographies and carotid or peripheral vascular angiographies [1]. Contrast staining has most often been reported in acute ischemic stroke (AIS) patients who are receiving thrombolytic therapy [2–5]; however, CS has rarely been described in AIS patients who are undergoing conservative medical treatment, have chronic kidney disease, and have recently received a contrast agent. We report the case of a 75-year-old man with a medical history of hypertension, diabetes mellitus, and end-stage renal disease who was on hemodialysis and underwent a percutaneous coronary intervention (PCI) for stable ischemic heart disease 2 days before arriving at our ED. The complex technique of rotational atherectomy was performed during the PCI procedure to alleviate severe calcification of the coronary arteries; he was then discharged uneventfully. Unfortunately, when he
D
P
R O
arrived in our ED, he had been unable to hold chopsticks for the previous 10 hours. Upon arrival, his blood pressure was 186/104 mm Hg, his heart rate was 96 beats per minute, and his respiratory rate was 22 breaths per minute. A physical examination indicated that the muscle power score of his right side extremities was a 2, and he had a National Institutes of Health Stroke Scale score of 6. A brain CT scan demonstrated a sulcal or cortical hyperdense lesion in the left frontal lobe (Fig. 1). As this is an unusual area for subarachnoid or cerebral hemorrhaging, an urgent brain magnetic resonance imaging (MRI) scan was performed to confirm the diagnosis. Diffusion-weighted imaging revealed a highintensity signal in the left precentral gyrus (Fig. 2A, white arrow) with a corresponding low-intensity signal revealed via apparent diffusion coefficient imaging (Fig. 2B, white arrow), which was consistent with acute cerebral infarction. Contrast medium administered during the PCI procedure 2 days prior had leaked from the damaged blood-brain barrier and resulted in CS, as shown by the brain CT scan of this patient with end-stage renal disease. If physicians misinterpret CS as a hemorrhagic transformation (HT), they might incorrectly decide to discontinue dual antiplatelet treatment, which could cause serious adverse effects such as subacute thrombosis or death in patients such as ours, who had just undergone the implantation of stents 2 days prior. The interruption of dual antiplatelet treatment within 7 days of starting the treatment has been associated with a notable increase in cardiac death [6]. The therapeutic goal of blood pressure control is also very different for AIS with CS than it is for HT. Therefore, establishing an accurate diagnosis was vital for our patient, who had neurologic deficits and was recently administered contrast. Contrast staining on brain CT scans was most often reported in AIS patients receiving thrombolytic therapy and being administered contrast; the incidence of CS was 31% to 60% among these patients [2–5]. In patients receiving intraarterial tissue plasminogen activator (IAtPA), approximately 90% of patients with CS were observed to develop HF in follow-up CT scans within 24 hours, indicating that IAtPA increased the risk of HT in these patients [2]. Notably, there was a conflicting result from another study that did not show HF in follow-up CT scans within 48 to 72 hours in those receiving mechanical thrombectomy rather than IAtPA [3]. The risk of HT in our patient, who was not receiving thrombolytic therapy, should have been very low, similar to patients not receiving IAtPA. Differentiating CS from HT after AIS was dependent on the presence of anatomical boundaries and on the absence of a significant mass effect and surrounding edema [5]. Hounsfield unit values of more than 90 U, as an upper threshold, were thought to be a diagnostic indicator of CS, whereas a Hounsfield unit value of 40 U was used as a lower diagnostic threshold [5,7]. Based on the above criteria for the diagnosis of CS, the incidence of HT remained as high as 6% [1,2]. Using dual-energy CT to accurately differentiate hemorrhage from CS had
E
17 18
T
15 16
C
13 14
E
11 12
R R
9 10
Abstract A hyperdense lesion observed in a computed tomographic (CT) image of the brain is usually suspected to be a hemorrhage during an emergency evaluation. Other rare differential diagnoses include contrast-induced encephalopathy (CIN) and acute cerebral infarction with contrast staining (CS). Recent contrast administration is a common risk factor for both CIN and CS. The former has been associated with favorable neurologic outcomes, whereas CS might have complications, such as hemorrhagic transformation (HT). Contrast staining on brain CT scans was most often reported in acute ischemic stroke patients receiving thrombolytic therapy and being administered contrast; the incidence of CS was 31% to 60% among these patients. Differentiating CS from HT after acute ischemic stroke was dependent on the presence of anatomical boundaries and on the absence of a significant mass effect and surrounding edema. The Hounsfield unit scale was also used to differentiate contrast or hemorrhage alone from mixed contrast and hemorrhage on brain CT scans. Clarifying the properties of a hyperdense lesion on a brain CT scan is essential because the therapeutic strategies for treating CS vs HT are completely different, including differences in the therapeutic goal of controlling blood pressure and in the use of antiplatelet agents. We report a rare condition in which CS developed in an elderly patient because of end-stage renal disease, but the patient was not receiving thrombolytic therapy. An urgent brain magnetic resonance imaging scan was used to confirm the diagnosis of CS, which further guided the treatment of this patient.
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2
0735-6757/© 2016 Published by Elsevier Inc.
Please cite this article as: Ho S-K, et al, Differentiating contrast staining after acute ischemic stroke from hemorrhagic transformation during emergency evaluation, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.035
51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 Q2 83 84 85 86 87 88 89 90 91 92 93 94 95 96
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S-K. Ho et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx
Yen-Jun Lai 116 Neuroradiology, Diagnostic and Interventional Department of Medical 117 Imaging, Far Eastern Memorial Hospital, New Taipei City, Taiwan 118 119
Tzu-Chiao Lin 120 Division of Cardiology, Department of Internal Medicine, Tri-Service 121 General Hospital, National Defense Medical Center, Taipei, Taiwan 122
105 106 107 108 109 110 111 112 113 114
Sing-Kong Ho Cardiology Division of Cardiovascular Medical Center Far Eastern Memorial Hospital, New Taipei City, Taiwan Jen-Kuang Lee Division of Cardiology, Department of Internal Medicine National Taiwan University Hospital, Taipei, Taiwan
129 130 131 132 133
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[1] Kocabay G, Karabay CY, Kalayci A, Akgun T, Guler A, Oduncu V, et al. Contrast-induced neurotoxicity after coronary angiography. Herz 2014;39(4):522–7. [2] Nakano S, Iseda T, Yoneyama T, Wakisaka S. Early CT signs in patients with acute middle cerebral artery occlusion: incidence of contrast staining and haemorrhagic transformations after intra-arterial reperfusion therapy. Clin Radiol 2006;61(2):156–62. [3] Parrilla G, Garcia-Villalba B, Espinosa de Rueda M, Zamarro J, Carrion E, HernandezFernandez F, et al. Hemorrhage/contrast staining areas after mechanical intraarterial thrombectomy in acute ischemic stroke: imaging findings and clinical significance. AJNR Am J Neuroradiol 2012;33(9):1791–6. [4] Phan CM, Yoo AJ, Hirsch JA, Nogueira RG, Gupta R. Differentiation of hemorrhage from iodinated contrast in different intracranial compartments using dual-energy head CT. AJNR Am J Neuroradiol 2012;33(6):1088–94. [5] Amans MR, Cooke DL, Vella M, Dowd CF, Halbach VV, Higashida RT, et al. Contrast staining on CT after DSA in ischemic stroke patients progresses to infarction and rarely hemorrhages. Interv Neuroradiol 2014;20(1):106–15. [6] Mehran R, Baber U, Steg PG, Ariti C, Weisz G, Witzenbichler B, et al. Cessation of dual antiplatelet treatment and cardiac events after percutaneous coronary intervention (PARIS): 2 year results from a prospective observational study. Lancet. 382(9906): 1714–22. [7] Mericle RA, Lopes DK, Fronckowiak MD, Wakhloo AK, Guterman LR, Hopkins LN. A grading scale to predict outcomes after intra-arterial thrombolysis for stroke complicated by contrast extravasation. Neurosurgery 2000;46(6):1307–14. [8] Schindlbeck KA, Santaella A, Galinovic I, Krause T, Rocco A, Nolte CH, et al. Spot sign in acute intracerebral hemorrhage in dynamic T1-weighted magnetic resonance imaging. Stroke 2016;47(2):417–23.
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References
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the advantages of 100% sensitivity and 92.8% specificity, but calcification was a major limitation [4]. Although time consuming and difficult to use in patients who have a critical illness, MRI enables the detection of a hemorrhage with more accuracy than a CT, and hemorrhages are associated with poor clinical outcomes [8]. It is essential to establish accurate diagnoses in patients who present with neurologic deficits and have recently been exposed to a contrast agent, especially patients with chronic kidney disease. Because a brain CT may not result in a definite diagnosis, an urgent MRI is necessary to distinguish CS from HT after AIS.
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http://dx.doi.org/10.1016/j.ajem.2016.05.035
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Fig. 1. A brain CT scan revealed a hyperdense sulcal or cortical lesion in the left frontal lobe (white arrow).
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Cheng-Wei Liu Division of Cardiology, Department of Internal Medicine Tri-Service General Hospital, Songshan Branch National Defense Medical Center Taipei, Taiwan Corresponding author at: Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, Songshan Branch National Defense Medical Center Taipei, No.131, Jiankang Rd Songshan District, Taipei City, 105, Taiwan (ROC) Tel.: +886 910682383; fax: +886 2 28837372 E-mail address: [email protected]
Fig. 2. A brain MRI scan revealed a high-intensity signal in the left precentral gyrus using diffusion-weighted imaging (A, white arrow) with a corresponding low-intensity signal shown via apparent diffusion coefficient imaging (B, white arrow).
Please cite this article as: Ho S-K, et al, Differentiating contrast staining after acute ischemic stroke from hemorrhagic transformation during emergency evaluation, Am J Emerg Med (2016), http://dx.doi.org/10.1016/j.ajem.2016.05.035
137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 Q3 156 157 158 159 160 161