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.