Spot sign score predicts rapid bleeding in spontaneous intracerebral hemorrhage

This study was conducted to determine whether spot sign score correlates with average rate of hematoma expansion and whether average rate of expansion predicts in-hospital mortality and clinical outcome in spontaneous intracerebral hemorrhage (ICH). The study included 367 patients presenting to the Emergency Department (ED) from January 1, 2000 to December 31, 2008 with nontraumatic ICH. All received noncontrast computed tomography (NCCT) of the head and multidetector CT angiography (MDCTA) on presentation to the ED and a follow-up NCCT within 48 h. Imaging was used to determine the hematoma location and volume, average rate of expansion, and spot sign score. Primary outcome measures included in-hospital mortality and clinical outcome based on modified Rankin Scale at 3 months or at discharge. Regression analysis was performed to correlate spot sign score and average rate of hematoma expansion. ICH expansion was identified in 194 of 367 patients (53%). In a multivariate analysis, rate of ICH expansion predicted mortality (hazard ratio 1.1, CI 1.08-1.12, p?相似文献   

Contrast extravasation on CT predicts mortality in primary intracerebral hemorrhage

BACKGROUND AND PURPOSE: Recent studies of intracerebral hemorrhage (ICH) treatments have highlighted the need to identify reliable predictors of hematoma expansion. The goal of this study was to determine whether contrast extravasation on multisection CT angiography (CTA) and/or contrast-enhanced CT (CECT) of the brain is associated with hematoma expansion and increased mortality in patients with primary ICH.MATERIALS AND METHODS: All patients with primary ICH who underwent CTA and CECT, as well as follow-up noncontrast CT (NCCT) before discharge/death from January 1, 2003, to September 30, 2005, were retrospectively identified. One neuroradiologist reviewed admission and follow-up NCCT for hematoma size and growth. A second neuroradiologist independently reviewed CTA and CECT for active contrast extravasation. Univariate and multivariate logistic regression analyses were performed to evaluate the significance of clinical and radiologic variables in predicting 30-day mortality, designated as the primary outcome. Hematoma growth was considered as a secondary outcome.RESULTS: Of 56 patients, contrast extravasation was seen in 17.9% of patients on initial CTA and in 23.2% of patients on initial CECT following CTA. Univariate analysis showed that the presence of extravasation on CT, large initial hematoma size (>30 mL), the presence of “swirl sign” on NCCT, the Glasgow Coma Scale and ICH scores, and international normalized ratio were associated with increased mortality. On multivariate analysis, only contrast extravasation on CT (P = .017) independently predicted mortality. Contrast extravasation on CT (P < .001) was also an independent predictor of hematoma growth on multivariate analysis.CONCLUSION: Active contrast extravasation on CT in patients with primary ICH independently predicts mortality and hematoma growth.

Primary intracerebral hemorrhage (ICH) is one of the most devastating forms of stroke, with 30-day mortality rates ranging from 35% to 44%.^1–3 Recent studies of hemostatic treatments such as recombinant activated factor VII as a means to reduce hematoma growth and impact clinical outcome in patients with primary ICH have highlighted the need to identify reliable predictors of hematoma expansion.^4–6 A number of clinical and radiologic variables have been associated with poor outcome following ICH, including age; blood glucose level; Glasgow Coma Scale (GCS) score; and hemorrhage location, size, and intraventricular extension.^7–12 Several prognostic models for ICH have been developed incorporating both clinical and radiologic variables, among them the ICH score, which includes the GCS score, advanced age, hematoma location, ICH volume, and the presence of intraventricular hemorrhage, to predict 30-day mortality.¹³Nearly all studies of prognostic variables with respect to imaging have focused exclusively on noncontrast CT (NCCT). One study by Becker et al from 1999¹⁴ examined the role of iodinated contrast administration in primary ICH, concluding that contrast extravasation was independently associated with increased mortality. However, CT technology has evolved considerably since 1999, primarily due to the introduction of multisection CT scanners. High-quality CT angiography (CTA) and contrast-enhanced CT (CECT) studies of the brain are now routinely performed following contrast administration. The respective roles of CTA and CECT were not separately defined in Becker''s study, in which single-section CT scanner technology was used.¹⁴ A recent study by Goldstein et al¹⁵ demonstrated an independent association between contrast extravasation and hematoma expansion but did not explore the relationship with mortality.The goal of this study was to determine whether contrast extravasation as visualized on multisection CTA and/or CECT is associated with hematoma expansion and increased mortality in patients with primary ICH.     

脑出血患者早期造影剂外渗率的临床意义简

目的：脑出血患者CT造影外渗率可提示血肿扩大,本研究评价脑灌注CT（PCT）推导表面渗透性（PS）是否可检测早期CT造影剂外渗率差异及其意义。方法20例脑出血患者入院时及入院24 h后进行CT检查,入院时进行PCT-PS扫描。采用Wilcoxon秩和检验比较下列兴趣区的PS值：①斑点征病灶;②造影剂渗漏（PCCT-L）病灶;③排除外渗的血肿;④外渗至对侧区域;⑤无外渗患者的血肿;⑥无外渗患者血肿的对侧面积。此外,比较24 h后的血肿扩展情况。结果上述6项参数的PS分别为（6．5±1．6）、（1．0±0．4）、（0．12±0．39）、（0．26±0．09）、（0．4±0．3）、（0．09±0．32）ml×min-1×（100 g）-1。斑点征病灶的PS值和PCCT-L病灶的PS与其他几项参数比较差异有统计学意义（P＜0．05）。外渗阳性患者的血肿体积由（34±41）ml增加至（40±46）ml,外渗阴性患者则由（20±32）ml降至（17±27）ml。结论与PCCT-L病灶和血肿比较,PCT-PS参数检测显示CTA斑点征病灶造影剂较高外渗率,早期外渗与血肿扩展相关。     

Role of prothrombin complex concentrate (PCC) in Acute Intracerebral Hemorrhage with Positive CTA spot sign: An institutional experience at a regional and state designated stroke center

Purpose

Our objective is to identify the effect of prothrombin complex concentrate (PCC) in acute intracranial hemorrhage (ICH) by evaluating intraparenchymal hematoma expansion between initial and follow-up head CT at 5–24 h, in those with positive CTA spot sign (CTASS). CTASS is an independent predictor of hematoma growth (1). Acute ICH, regardless of etiology, can present with quick mental status decline often resulting in irreversible brain damage. Hematoma expansion appears to be a modifiable predictor of clinical outcome and an appropriate target for medical therapy. PCC is a procoagulant which is the agent of choice in warfarin-related ICH. We explore utility of PCC in all patients regardless of warfarin status.

Materials and methods

We retrospectively reviewed patients with ICH at our NY State designated Stroke Center from Nov 2013 to Dec 2015. Twenty-three of the 85 patients with ICH received PCC, of which 8 had positive CTASS (E = 8). Four of the 62 patients without PCC, had a positive CTASS (C = 4). Interval change in ICH volume at 5–24 h was measured using ABC/2 formula, which is an accurate predictor of ICH volume (5).

Results

Control group (C) showed increase in mean ICH volume of 46% (SD = 37.3%), whereas experimental group (E) showed a decrease of 13% (SD = 29.9%) (p value = 0.012).

Conclusions

We found a strong statistical correlation favoring our hypothesis. Use of PCC in active ICH with positive CTASS resulted in overall decrease in the mean hematoma size at 24 h, whereas the control group showed an overall increase.

     

“Dynamic spot sign” on CT perfusion source images predicts haematoma expansion in acute intracerebral haemorrhage

Objectives

To evaluate the association between dynamic progressive enhancing foci (“dynamic spot sign”) in acute haematoma on CT perfusion source images (CTP-SI) and haematoma expansion.

Methods

One hundred twelve consecutive patients with spontaneous intracerebral haemorrhage according to unenhanced CT, CTP and CT angiography within 6 h of symptom onset were prospectively evaluated. Patients were dichotomised according to the presence/absence of the dynamic spot sign on CTP-SI in haematoma. The predictive value of haematoma expansion was analysed.

Results

Haematoma expansion was detected in 28 patients (25.0 %) on follow-up unenhanced CT images. Thirty patients (26.8 %) demonstrated the dynamic spot sign on CTP-SI, about 83.3 % of patients with haematoma expansion (P?<?0.001). Sensitivity, specificity, positive predictive value, negative predictive value and kappa value for expansion were 89.3 %, 94.0 %, 96.3 %, 83.3 % and 0.814, respectively. In multiple regression, the presence of the CTP dynamic spot sign within acute haematomas independently predicted haematoma expansion; the univariate analysis OR value was 131.667 (29.386–590.289), P?<?0.0001. Moreover, the multivariate analysis CTP dynamic spot sign OR value was 203.996 (32.123–1295.488), P?<?0.0001.

Conclusions

The CTP-SI dynamic spot sign is associated with acute haematoma expansion, is more direct in showing active ongoing bleeding and has a higher predictive value than the CTA spot sign.

Key Points

? It is important to identify potential progression of spontaneous intracerebral haemorrhage. ? Dynamic enhancement within CT perfusion source images is associated with haemorrhage expansion. ? The CTP dynamic spot sign may be present throughout arterial to venous phase imaging. ? The CTP dynamic spot sign carries a higher predive value for haematoma expansion than CTA.     

Prosthetic vascular graft infection imaging

PurposeWe are reporting our experience with imaging of vascular graft infections using computed tomography angiography (CTA), white blood cell (WBC) scintigraphy and software-based fusion imaging.Material and methodsInstitutional review board approval was obtained. We performed a retrospective review of patients who had clinical signs and symptoms of vascular graft infection in whom both WBC single photon emission computed tomography (SPECT) and CTA was performed between 2005 and 2010. We performed fusion imaging with available data using software coregistration technique and analyzed outcome of the patients.ResultsWe had 20 patients; 11 had grafts of the aorta, five had peripheral vascular grafts, three had aortic and peripheral vascular grafts, and one had a thoracic aortic graft. WBC imaging was positive in 10 patients, negative in six patients and indeterminate in 4 patients. CTA was positive in six patients, negative in four patients and indeterminate in 10 patients. Sensitivity, specificity, accuracy, positive predictive value and negative predictive value (NPV) for WBC, CTA and WBC SPECT/CTA fusion were 75/100/80/100/50%, 88/50/80/88/50% and 94/50/85/88/67% respectively.ConclusionThe use of CTA, WBC scintigraphy, and image co-registration influenced the diagnostic confidence of graft infection and the outcome of the patients. Software-based fusion imaging of both modalities resulted in improved sensitivity, accuracy, and NPV.     

双能量CTA在急性脑血肿扩大的预测价值

目的:探索双能量CTA在预测脑血肿早期扩大的应用价值.方法:收集167例急性脑出血患者的临床及影像资料,其中血肿扩大组57例,血肿无扩大组110例.采用条件向前法将两组间差异有统计学意义的临床指标及影像特征纳入logistic回归分析,计算受试者工作特征(ROC)曲线下面积来评估这些变量预测血肿扩大的效能.结果:血肿扩...     

脑血管CTA预测高血压脑出血患者血肿扩大的临床分析

 目的 分析脑血管CTA检查中造影剂外渗与急性期高血压脑出血血肿扩大的关系。 方法 63例急性期高血压脑出血患者入院后行头颅CT及脑血管CTA检查,24 h后复查头颅CT,观察造影剂外渗情况,分析脑 血管CTA检查过程中造影剂外渗与血肿扩大的关系。 结果 血肿扩大组11例(17.46%),血肿无扩大组52例 (82.54%)。血肿扩大11例患者中造影剂外渗者9例,CTA阳性预测血肿扩大准确率81.82%,造影剂外渗患者血肿量增加（27.63 ±11.52）ml,造影剂无外渗患者血肿量增加（3.12±1.48）ml（ P =0.006）,血肿扩大组血肿量增加（20.18±12.27） ml,血肿无扩大组出血量增加（1.59±1.05） ml（ P =0.027）。 结论 在脑血管CTA检查中,造影剂外 渗与急性期高血压脑出血血肿扩大有明显相关性,可预测高血压脑出血血肿扩大情况。     

Follow-up of endovascular aortic aneurysm repair: Preliminary validation of digital tomosynthesis and contrast enhanced ultrasound in detection of medium- to long-term complications

AIM: To validate the feasibility of digital tomosynthesis of the abdomen (DTA) combined with contrast enhanced ultrasound (CEUS) in assessing complications after endovascular aortic aneurysm repair (EVAR) by using computed tomography angiography (CTA) as the gold standard. METHODS: For this prospective study we enrolled 163 patients (123 men; mean age, 65.7 years) referred for CTA for EVAR follow-up. CTA, DTA and CEUS were performed at 1 and 12 mo in all patients, with a maximum time interval of 2 d. RESULTS: Among 163 patients 33 presented complications at CTA. DTA and CTA correlated for the presence of complications in 32/33 (96.96%) patients and for the absence of complications in 127/130 (97.69%) patients; the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of DTA were 97%, 98%, 91%, 99%, and 98%, respectively. CEUS and CTA correlated for the presence of complications in 19/33 (57.57%) patients and for the absence of complications in 129/130 (99.23%) patients; the sensitivity, specificity, PPV, NPV and accuracy of CEUS were 58%, 99%, 95%, 90%, and 91%, respectively. Sensitivity, specificity and accuracy of combining DTA and CEUS together in detecting EVAR complications were 77%, 98% and 95%, respectively. CONCLUSION: Combining DTA and CEUS in EVAR follow-up has the potential to limit the use of CTA only in doubtful cases.     

Fellows' Journal Club: Contrast Extravasation on CT Angiography Predicts Hematoma Expansion and Mortality in Acute Traumatic Subdural Hemorrhage

BACKGROUND AND PURPOSE:The presence of active contrast extravasation at CTA predicts hematoma expansion and in-hospital mortality in patients with nontraumatic intracerebral hemorrhage. This study aims to determine the frequency and predictive value of the contrast extravasation in patients with aSDH.MATERIALS AND METHODS:We retrospectively reviewed 157 consecutive patients who presented to our emergency department over a 9-year period with aSDH and underwent CTA at admission and a follow-up NCCT within 48 hours. Two experienced readers, blinded to clinical data, reviewed the CTAs to assess for the presence of contrast extravasation. Medical records were reviewed for baseline clinical characteristics and in-hospital mortality. aSDH maximum width in the axial plane was measured on both baseline and follow-up NCCTs, with hematoma expansion defined as >20% increase from baseline.RESULTS:Active contrast extravasation was identified in 30 of 199 discrete aSDHs (15.1%), with excellent interobserver agreement (κ = 0.80; 95% CI, 0.7–0.9). The presence of contrast extravasation indicated a significantly increased risk of hematoma expansion (odds ratio, 4.5; 95% CI, 2.0–10.1; P = .0001) and in-hospital mortality (odds ratio, 7.6; 95% CI, 2.6–22.3; P = 0.0004). In a multivariate analysis controlled for standard risk factors, the presence of contrast extravasation was an independent predictor of aSDH expansion (P = .001) and in-hospital mortality (P = .0003).CONCLUSIONS:Contrast extravasation stratifies patients with aSDH into those at high risk and those at low risk of hematoma expansion and in-hospital mortality. This distinction could affect patient treatment, clinical trial selection, and possible surgical intervention.

Acute traumatic subdural hemorrhage carries a mortality rate of 68% in patients who are in a coma at the time of presentation.^1–4 The incidence of aSDH is approximately 21% in patients with severe TBI⁴ and decreases to 11% in patients with mild and moderate TBI.⁵ Mortality secondary to aSDH has been related to initial hematoma size, the presence of additional brain injury, midline shift, comatose state, and delay in hematoma evacuation >2 hours after arrival to the emergency department.^6,7 The decision to undertake surgical intervention versus expectant management of aSDH is based on hematoma size, the presence of midline shift, admission GCS score, and hematoma growth.⁸ Early hematoma evacuation (<4 hours) has been shown to improve intracranial pressure and therefore brain perfusion, with a decrease in mortality compared with delayed surgical intervention in comatose patients with severe TBI.⁴ Although a significant proportion of patients are treated nonoperatively (noncomatose patients and comatose patients with aSDH <10 mm in width and/or <5 mm of midline shift), a subset of these aSDHs will expand, necessitating delayed operative intervention. The strong relationship between mass effect and mortality suggests that hematoma expansion is probably deleterious for brain perfusion and clinical outcome.⁹ However, to date, no reliable predictors of aSDHs expansion in the initial 48 hours have been identified. Identifying such a predictor may be helpful in the clinical decision to triage patients to early surgical intervention versus expectant management.Prior studies have found that the presence of active contrast extravasation at CTA, defined as the spot sign, is a powerful predictor of hematoma expansion and in-hospital mortality in patients with primary intracerebral hemorrhage.^9–15 However, to date, no studies have assessed the frequency and predictive value of this important finding in patients with aSDH.In our emergency department, CTA of the head and neck is frequently performed in patients who present with craniocervical trauma to detect vascular injury.^15,16 Subsets of these patients also have an associated aSDH. This study aims to determine the frequency and predictive value for hematoma expansion and in-hospital mortality of the CTA contrast extravasation in patients with aSDH.     

Thrombolytic therapy in myocardial infarction. Computerized tomography of encephalic complications]

PURPOSE: To evaluate the CT findings of intracerebral hemorrhage in patients undergoing thrombolytic therapy for acute myocardial infarction and to correlate the type of intracerebral hemorrhage with clinical outcome. MATERIAL AND METHODS: We retrospectively reviewed the clinical records and CT scans of intracerebral hemorrhage on a total of 302 patients who underwent thrombolytic therapy for acute myocardial infarction at our institution from January 1996 to September 1999. In each patient we evaluated: the number, sites and size of hemorrhage, and the presence and severity of mass effect. The site of the hemorrhage was classified as intraparenchymal, intraventricular, subdural and subarachnoid. RESULTS: Six patients (2%, mean age 74, range 66-80) developed intracerebral hemorrhage. There was a total of 22 hemorrhages: 1 subdural hemorrhage, 6 subarachnoid, 11 intraparenchymal and 4 intraventricular. Excluding intraventricular hemorrhage, 14/18 hemorr-hages were located supratentorially. In five patients there was a fluid-blood level. Three patients had severe mass effect with midline shift. Symptoms presented within 24 hours from the administration of thrombolytic therapy in all patients. All the patients who died had a large hematoma with a severe mass effect and a severe midline shift at CT scan. In the remaining patients, the hematoma was of medium size and no mass effect was seen. CONCLUSIONS: The most common site of hemorrhage was supratentorial and intraparenchymal. Large volume intracerebral hemorrhage, multiple hemorrhages and mass effect with midline shift were associated with increased mortality. The most commonly observed finding was a fluid-blood level hematoma.     

Spontaneous intracerebral hematomas from vascular causes

Summary The aim of the present study was to assess the diagnostic accuracy of CT in determining the underlying causes of brain hematomas with a state-of-the art CT. For this purpose, CT and angiographic data of 149 subjects with spontaneous intracerebral hematomas (ICH) were statistically compared in a blind, retrospective study, taking angiography, supported when possible by surgical findings, as providing the correct diagnoses. 5 groups were distinguished on the basis of CT data: 103 patients with isolated deep ICH had normal angiograms; 9 patients with isolated superficial ICH and 8 with deep ICH and intraventricular hemorrhage (IVH) had arteriovenous malformations (AVMs). 4 with this combination showed no angiographic abnormalities, one had an aneurysm. 14 subjects with ICH and subarachnoid hemorrhage (SAH) had a middle cerebral or carotid artery aneurysm; and 10 with ICH, SAH and IVH had also an aneurysm, in 7 on the anterior communicating artery. Sensitivity, specificity, positive and negative predictive values were respectively: for AVMs 100, 96, 77 and 100%; and for aneurysms 96, 100, 100 and 99%. Kendall coefficient was 0.95, indicating close correlation between the two modalities. This study confirms that CT can accurately predict the likelihood, nature and location of vascular ICHs. It indicates whether angiography is necessary or not, and if so, what vascular tree ought to be explored.     

Vasospasm after subarachnoid hemorrhage: utility of perfusion CT and CT angiography on diagnosis and management

PURPOSE: To evaluate the utility of perfusion CT (PCT) combined with CT angiography (CTA) for the diagnosis and management of vasospasm, by using conventional digital subtraction angiography (DSA) as the gold standard. METHODS: We retrospectively identified 27 patients with acute subarachnoid hemorrhage who had undergone CTA/PCT, DSA, and transcranial Doppler (TCD) ultrasonography within a time interval of 12 hours of one another. The patients' charts were reviewed for treatment of vasospasm. CTA, PCT, TCD, and DSA examinations were independently reviewed and quantified for vasospasm. PCT thresholds, CTA findings, noncontrast CT (NCT) hypodensities, and TCD thresholds were evaluated for accuracy, sensitivity, and specificity, as well as for negative (NPV) and positive predictive values (PPV) in the prediction of angiographic vasospasm and endovascular treatment, considering DSA as the gold standard. RESULTS: Thirty-five CTA/PCT, TCD, and DSA examinations were performed on these 27 patients. A total of 123 arterial territories in 11 patients demonstrated angiographic vasospasm. Six patients underwent endovascular therapy. CTA qualitative assessment and PCT-derived mean transit time (MTT) with a threshold at 6.4 seconds represented the most accurate (93%) combination for the diagnosis of vasospasm, whereas MTT considered alone represented the most sensitive parameter (NPV, 98.7%). A cortical regional cerebral blood flow value 相似文献   

Periaortic hematoma at diaphragmatic crura at helical CT: sign of blunt aortic injury in patients with mediastinal hematoma

PURPOSE: To evaluate periaortic hematoma (PH) near the level of the diaphragm at abdominal computed tomography (CT) as an indirect sign of acute traumatic aortic injury after blunt trauma in patients with mediastinal hematoma. MATERIALS AND METHODS: From 1998 to 2001, 97 patients with CT evidence of mediastinal hematoma after blunt thoracic trauma were retrospectively identified at two level 1 trauma centers. The presence or absence of PH near the level of the diaphragmatic crura was retrospectively established by a blinded reviewer at each institution. Aortic injury status was determined by reviewing angiographic, surgical, and clinical records. Sensitivity, specificity, positive and negative productive values, and positive and negative likelihood ratios were calculated. RESULTS: Among the 97 patients with mediastinal hematoma, 14 had both PH near the level of the diaphragm and aortic injury; six had aortic injuries without PH, five had PH near the level of the diaphragm without aortic injury, and 72 had no evidence of PH near the diaphragm and no aortic injury. Sensitivity for PH near the level of the diaphragm as a sign of aortic injury was 70%; specificity, 94%; positive predictive value, 74%; and negative predictive value, 92%. The positive likelihood ratio for the presence of aortic injury was 10.8, and the negative likelihood ratio was 0.3. CONCLUSION: PH near the level of the diaphragmatic crura is an insensitive but relatively specific sign for aortic injury after blunt trauma. The presence of this sign at abdominal CT should prompt imaging of the thoracic aorta to evaluate potential thoracic aortic injury.     

Nontraumatic lobar intracerebral hemorrhage: CT/angiographic correlation

Cerebral angiography in patients with nontraumatic lobar intracerebral hemorrhage may or may not uncover the underlying cause of the disorder. The CT and cerebral angiographic studies of 67 consecutive patients with nontraumatic lobar intracerebral hemorrhage were reviewed to assess the relationship between CT pattern and location of hemorrhage and the frequency of diagnostic angiographic findings. Origins of these hematomas were also determined and correlated with radiographic findings. CT revealed 26 temporal, 18 frontal, 17 parietal, three occipital, and three multiple lobar hematomas. Thirty-three patients had "pure" lobar hematomas, 12 had coexistent intraventricular hemorrhage, 12 had associated subarachnoid hemorrhage, and 10 had both intraventricular and subarachnoid hemorrhage accompanying their lobar hematomas. Angiographic findings were diagnostic in 29 cases (43%). In the presence of accompanying subarachnoid hemorrhage, angiographic findings were diagnostic in 17 (77%) of 22 patients; in its absence, angiography was diagnostic in 12 (27%) of the remaining 45 patients. Diagnostic angiograms were also more frequent in the presence of a frontal or temporal lobar hematoma than with a parietal or occipital lobar hematoma. While CT patterns do influence the frequency of diagnostic angiographic findings, cerebral angiography is recommended in all patients with otherwise unexplained nontraumatic lobar intracerebral hemorrhage.     

Computed tomography angiography in detection and characterization of ruptured anterior cerebral artery aneurysms at uncommon location for emergent surgical clipping

INTRODUCTION: Cerebral subarachnoid hemorrhage may result from rupture of saccular aneurysms at uncommon location [excluding the anterior communicating artery (ACOM)] of the anterior cerebral artery (ACA). The purpose of this study was to evaluate the usefulness of helical computed tomography angiography (CTA) in detection and characterization of intracranial aneurysms at such uncommon locations before emergent surgical clipping. MATERIALS AND METHODS: Between 1998 and 2003, records for 50 consecutive patients who underwent emergent surgical clipping for intracranial aneurysms were reviewed. Eighteen of these patients had aneurysms in the ACA. After those patients with unequivocal ACOM aneurysms were excluded, eight patients with eight aneurysms in an uncommon location of the ACA were recruited to this study. Plain computed tomography (CT) and CTA were performed in eight patients, and digital subtraction angiographies were done in three patients. Each aneurysm was evaluated for the detection, quantification, and characterization of the aneurysms with 2D multiplanar reformatted and 3D volume-rendering techniques. RESULTS: There were two small aneurysms arising from the A1 segment, one from the A2 segment, two at the junction of triplicated ACAs, two at the junction of A2 and A3 segments, and one at the junction of A2 and A3 segments of the azygos ACA. The average diameter of the aneurysmal sac was 4.44 mm (range, 2.7-7.0 mm), and the aneurysmal neck averaged 2.59 mm (range, 1.2-3.5 mm) in size. The smallest aneurysm measured 2.2x1.8x2.7 mm (neck, 1.2 mm) in the A1 segment of the left ACA. Three patients had intracerebral hematoma, seven had intraventricular hemorrhage, and three had acute hydrocephalus. CONCLUSION: Aneurysms in uncommon locations of ACAs exhibited characteristic features. Rupture of these aneurysms can cause intracerebral hematoma, intraventricular hemorrhage, and/or acute hydrocephalus. Noninvasive CTA can reliably detect and characterize intracranial aneurysms at such uncommon location for planning of emergent surgical intervention.     

Radiologic estimation of hematoma volume in intracerebral hemorrhage trial by CT scan

BACKGROUND AND PURPOSE: Therapeutic intervention during the early stages of an intracerebral hemorrhage (ICH) might have value in improving clinical outcomes. During the 73-site International Recombinant Activated Factor VII Intracerebral Hemorrhage Trial, CT techniques were used to monitor the change in hematoma volume in response to treatment. The use of CT imaging technology served 3 functions: to provide accurate measurements of the change in hematoma volume, intraventricular volume (IVH), and edema volume; to evaluate the use of CT scans as a predictor of patient outcomes; and to demonstrate that hematoma volume can serve as a surrogate marker for ICH clinical progression. METHODS: The multicenter clinical trial received institutional review board approval and obtained informed consent from the patient or a legally acceptable representative (waived in a few cases of incapacity, according to local and national regulations). CT scans were used to quantify volumes of hemorrhage and to monitor evolution over a 72-hour period in patients with ICH treated with placebo or 40, 80, or 160 microg/kg of recombinant activated factor VII (rFVIIa). CT image data were transmitted digitally to an imaging laboratory and analyzed by 2 readers masked to patient and treatment data, by using Analyze software, a fully integrated toolkit for interactive display, processing, and measurement of biomedical image data. The use of this software enabled the evaluation of intraclass variability of CT scan interpretations. RESULTS: Interpretations of ICH and IVH volumes of CT scans in patients treated in this study showed minimal intraclass variability. Variability was greatest for interpretations of edema volume. CONCLUSION: These CT assessments of lesions could have value in future early hemostatic interventions in ICH patients.     

Hypoattenuation on CT angiographic source images predicts risk of intracerebral hemorrhage and outcome after intra-arterial reperfusion therapy

BACKGROUND AND PURPOSE: Symptomatic hemorrhagic transformation (HT) is a significant complication of intravenous and catheter-based reperfusion. We hypothesized that the degree of vascular insufficiency, reflected as hypoattenuation on initial CT angiography (CTA) axial source images, is predictive of HT risk in stroke patients receiving intra-arterial reperfusion therapy. METHODS: We examined initial CTA source images and follow-up CT scans in 32 consecutive patients. Regions of interest were semiautomatically segmented and reviewed. Mean intensity was determined in the region of maximal hypoattenuation and in normal contralateral tissue, and the arithmetic difference (deltaHU) calculated. Receiver operator characteristic (ROC) curves and cross-validation were used to identify threshold deltaHU values. RESULTS: Thirteen patients had HT on follow-up CT (seven with parenchymal hematoma, six with hemorrhagic infarction). Patients with and those without HT did not differ in age, blood glucose level, lesion volume, or time to treatment or recanalization, though the former had a greater mean deltaHU (9.0 vs 6.3, P = .006). The ROC threshold at deltaHU > or = 8.1 was 69% sensitive and 90% specific for patients who developed HT (odds ratio = 19.1; 95% confidence interval: 2.9, 125; P = .002) and was predictive of poor clinical outcome (modified Rankin scale score > 2, P = .03). Neither HT in general nor parenchymal hematoma subtype was associated with poor outcome. CONCLUSION: The degree of hypoattenuation on initial CTA source images is a risk factor for HT and poor clinical outcome after intra-arterial reperfusion therapy. Prospective validation of this relationship in large populations may permit feasible real-time risk stratification.     

To reduce routine computed tomographic angiography for thoracic aortic injury assessment in level II blunt trauma patients using three mediastinal signs on the initial chest radiograph: a preliminary report

Purpose

CTA is routinely ordered on level II blunt thoraco-abdominally injured patients for assessment of injury to the thoracic aorta. The vast majority of such assessments are negative. The question being asked is, Does the accurate interpretation of the three mediastinal signs permit reliable determination of which patients need CTA for aortic assessment? The purpose of this investigation was to evaluate the role of three specifically selected mediastinal anatomic signs on the initial supine chest radiograph (CXR) of adult level II blunt thoraco-abdominally injured patients for the presence or absence of a mediastinal hematoma. The presence of a mediastinal hematoma is typically used as an indicator for computed tomographic angiography (CTA). The three mediastinal signs are the right para-tracheal stripe (RPTS), left para-spinal line (LPSL), and the left apical extra-pleural area (LAPA).

Materials and methods

The patient triage designation (level II trauma) was made by the attending physician at the time of admission. The initial CXR image and the CTA report of the 197 adult blunt level II thoraco-abdominally injured patients obtained on the day of admission were compared. The CXR of each of the 197 patients was independently assessed by each of four observers specifically for the status of the three mediastinal signs. Each observer was blinded to the CTA report until after the status of the three mediastinal sign evaluation had been determined. Two or three of the mediastinal signs being positive were required to determine that the CXR was positive for a mediastinal hematoma.

Results

Two or three of the selected mediastinal signs were normal in 192 (97.5%) patients. None of these patients had either a mediastinal hematoma or a major aortic injury on CTA. In each of the remaining five (2.5%) patients, two or three of the mediastinal signs were abnormal. Each of these patients had a mediastinal hematoma and a major thoracic aortic injury on CTA.

Conclusions

This preliminary study suggests that the accurate interpretation of the three specifically selected mediastinal signs on the initial supine CXR of adult level II blunt thoraco-abdominally injured patients could reduce the need for routine CTA for thoracic aortic injury assessment, and requires verification by an additional study.

     

Perimesencephalic subarachnoid hemorrhage: when to stop imaging?

To evaluate the yield of digital subtraction angiography (DSA) and repeated follow-up imaging in patients with initial pattern of perimesencephalic subarachnoid hemorrhage (PSAH) and negative computed tomography angiography (CTA) in excluding an underlying aneurysm. We conducted a retrospective analysis of all nontraumatic SAH who underwent a DSA between January 2006 and January 2010 and selected those with a PSAH pattern on CT done within 72 h from ictus. All CTAs were performed with a 64-section multidetector row CT scanner, and findings were compared with DSA and to follow-up imaging. Forty-nine patients with initial PSAH pattern and negative CTA who underwent subsequent DSA were identified. Six patients were excluded because CTA was not available in hospitals or 72 h after ictus. Only one patient (2.4%) had a false negative CTA with a 1-mm left ICA aneurysm seen on DSA, considered not to be the source of hemorrhage. An average of 2.0 ± 1.2 follow-up exams per patient (range 0–5) revealed no source of bleeding. One patient had a procedure-related transient complication, but evolved with no sequels. In patients with PSAH, CTA is reliable for ruling out an underlying aneurysm. DSA and, especially, further follow-up imaging have no increased diagnostic yield compared to initial negative CTA.