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Wada T, Takayama K, Myouchin K, Kishida H, Chanoki Y, Oshima K, Masutani T, Uchiyama Y, Tanaka T. Symptomatic Intracranial Hemorrhage after Mechanical Thrombectomy - the Difference between Iso-Osmolar and Low-Osmolar Contrast Media. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 18:18-23. [PMID: 38260038 PMCID: PMC10800169 DOI: 10.5797/jnet.oa.2023-0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/12/2023] [Indexed: 01/24/2024]
Abstract
Objective Symptomatic intracranial hemorrhage (SICH) after mechanical thrombectomy (MT) is generally considered a critical complication. Hemorrhagic transformation after ischemic stroke has also been associated with contrast media administration. The objective of our study was to evaluate correlations between contrast media type and incidence of SICH after MT. Methods Ninety-three consecutive patients (41 men; mean age, 80.2 years; range, 44-98 years) underwent MT reperfusion (expanded thrombolysis in cerebral infarction score, 2a-3) for acute large-vessel occlusion ischemic stroke within 8 h after symptom onset between April 2020 and July 2023 were retrospectively reviewed. Correlations between contrast media type (iso-osmolar or low-osmolar medium) and incidence of SICH were assessed. Results Contrast media were iso-osmolar in 60 cases or low-osmolar in 33 cases. The overall incidence of SICH was 5.5%. The frequency of SICH was significantly lower in the iso-osmolar group (1.7%) than in the low-osmolar group (12.1%; P = 0.033). Conclusion Iso-osmolar contrast media was associated with a lower incidence of SICH compared with low-osmolar contrast media in patients after MT.
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Affiliation(s)
- Takeshi Wada
- Department of Interventional Neuroradiology/Radiology, Kouseikai Takai Hospital, Tenri, Nara, Japan
| | - Katsutoshi Takayama
- Department of Interventional Neuroradiology/Radiology, Kouseikai Takai Hospital, Tenri, Nara, Japan
| | - Kaoru Myouchin
- Department of Interventional Neuroradiology/Radiology, Kouseikai Takai Hospital, Tenri, Nara, Japan
| | - Hayato Kishida
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
| | - Yuto Chanoki
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
| | - Keisuke Oshima
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
| | - Takahiro Masutani
- Departments of Neurosurgery, Ishinkai Yao General Hospital, Yao, Osaka, Japan
| | - Yoshitomo Uchiyama
- Departments of Neurosurgery, Ishinkai Yao General Hospital, Yao, Osaka, Japan
| | - Toshihiro Tanaka
- Department of Radiology, Nara Medical University, Kashihara, Nara, Japan
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Moser F, Todoran T, Ryan M, Baker E, Gunnarsson C, Kellum J. Hemorrhagic Transformation Rates following Contrast Media Administration in Patients Hospitalized with Ischemic Stroke. AJNR Am J Neuroradiol 2022; 43:381-387. [PMID: 35144934 PMCID: PMC8910803 DOI: 10.3174/ajnr.a7412] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 11/21/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Hemorrhagic transformation is a critical complication associated with ischemic stroke and has been associated with contrast media administration. The objective of our study was to use real-world in-hospital data to evaluate the correlation between contrast media type and transformation from ischemic to hemorrhagic stroke. MATERIALS AND METHODS We obtained data on inpatient admissions with a diagnosis of ischemic stroke and a record of either iso-osmolar or low-osmolar iodinated contrast media for a stroke-related diagnostic test and a treatment procedure (thrombectomy, thrombolysis, or angioplasty). We performed multivariable regression analysis to assess the relationship between contrast media type and the development of hemorrhagic transformation during hospitalization, adjusting for patient characteristics, comorbid conditions, procedure type, a threshold for contrast media volume, and differences across hospitals. RESULTS Inpatient visits with exclusive use of either low-osmolar (n = 38,130) or iso-osmolar contrast media (n = 4042) were included. We observed an overall risk reduction in hemorrhagic transformation among patients who received iso-osmolar compared with low-osmolar contrast media, with an absolute risk reduction of 1.4% (P = .032), relative risk reduction of 12.5%, and number needed to prevent harm of 70. This outcome was driven primarily by patients undergoing endovascular thrombectomy (n = 9211), in which iso-osmolar contrast media was associated with an absolute risk reduction of 4.6% (P = .028), a relative risk reduction of 20.8%, and number needed to prevent harm of 22, compared with low-osmolar contrast media. CONCLUSIONS Iso-osmolar contrast media was associated with a lower rate of hemorrhagic transformation compared with low-osmolar contrast media in patients with ischemic stroke.
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Affiliation(s)
- F.G. Moser
- From the Department of Imaging (F.G.M.), Cedars-Sinai Medical Center, Los Angeles, California
| | - T.M. Todoran
- Divisions of Cardiology and Vascular Surgery, Medical University of South Carolina (T.M.T.), Charleston, South Carolina
| | - M. Ryan
- MPR Consulting (M.R.), Cincinnati, Ohio
| | - E. Baker
- CTI Clinical Trial & Consulting Services (E.B., C.G.), Covington, Kentucky
| | - C. Gunnarsson
- CTI Clinical Trial & Consulting Services (E.B., C.G.), Covington, Kentucky
| | - J.A. Kellum
- Center for Critical Care Nephrology (J.A.K.), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Morales H, Lu A, Kurosawa Y, Clark JF, Tomsick T. Variable MR and pathologic patterns of hemorrhage after iodinated contrast infusion in MCA occlusion/reperfusion model. J Neurointerv Surg 2016; 9:1248-1252. [PMID: 27899518 DOI: 10.1136/neurintsurg-2016-012777] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/07/2016] [Accepted: 11/10/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To examine the hypothesis that IA reperfusion with iso-osmolar iodixanol, low-osmolar iopamidol, or saline causes different effects on MR signal changes and pathologic cut-brain section related to hemorrhagic transformation (HT) or iodinated radiographic contrast media (IRCM) deposition. METHODS Infarct was induced in 30 rats by middle cerebral artery suture occlusion. Reperfusion was performed after 5 hours with iso-osmolar iodixanol (n=9), low-osmolar iopamidol (n=12) or saline (n=9). MR images were obtained immediately after reperfusion and rats were sacrificed at 24 hours. Hypointense areas within the infarction on T2-weighted (T2-WI) or gradient echo (GRE) images were recorded and compared with HT on pathology. Fisher's exact test was used for proportions, and receiver operator curve analysis to evaluate MRI discrimination of hemorrhage. RESULTS Two types of HT were noted on pathology: confluent >0.2 mm petechial hemorrhage (PeH, 78%) or well-defined ≤0.2 mm hemorrhagic focus (HF, 22%). PeH was least common in the iodixanol subgroup (p<0.02). HF was more common in the IRCM group. Hypointense areas on T2-WI but not on GRE were significantly more common in the IRCM group (p<0.05). Hypointense areas on T2-WI and GRE discriminated HT (area under the curve: 0.714, p<0.002). CONCLUSIONS IRCM and saline induced different MRI signal and pathologic patterns in our sample. We postulate that T2 hypointensity with no GRE hypointensity might be associated with IRCM deposition; and decreased frequency of PeH after iodixanol infusion and the presence of HF almost exclusively in the IRCM group might represent a direct/indirect effect of contrast infusion/deposition in the brain parenchyma after reperfusion. Our results support previous observations in IMS III and are hypothesis generating.
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Affiliation(s)
- Humberto Morales
- Department of Radiology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Aigang Lu
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Yuko Kurosawa
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Joseph F Clark
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Thomas Tomsick
- Department of Radiology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
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Tomsick TA, Foster LD, Liebeskind DS, Hill MD, Carrozella J, Goyal M, von Kummer R, Demchuk AM, Dzialowski I, Puetz V, Jovin T, Morales H, Palesch YY, Broderick J, Khatri P, Yeatts SD. Outcome Differences between Intra-Arterial Iso- and Low-Osmolality Iodinated Radiographic Contrast Media in the Interventional Management of Stroke III Trial. AJNR Am J Neuroradiol 2015; 36:2074-81. [PMID: 26228892 DOI: 10.3174/ajnr.a4421] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 03/03/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Intracarotid arterial infusion of nonionic, low-osmolal iohexol contrast medium has been associated with increased intracranial hemorrhage in a rat middle cerebral artery occlusion model compared with saline infusion. Iso-osmolal iodixanol (290 mOsm/kg H2O) infusion demonstrated smaller infarcts and less intracranial hemorrhage compared with low-osmolal iopamidol and saline. No studies comparing iodinated radiographic contrast media in human stroke have been performed, to our knowledge. We hypothesized that low-osmolal contrast media may be associated with worse outcomes compared with iodixanol in the Interventional Management of Stroke III Trial (IMS III). MATERIALS AND METHODS We reviewed prospective iodinated radiographic contrast media data for 133 M1 occlusions treated with endovascular therapy. We compared 5 prespecified efficacy and safety end points (mRS 0-2 outcome, modified TICI 2b-3 reperfusion, asymptomatic and symptomatic intracranial hemorrhage, and mortality) between those receiving iodixanol (n = 31) or low-osmolal contrast media (n = 102). Variables imbalanced between iodinated radiographic contrast media types or associated with outcome were considered potential covariates for the adjusted models. In addition to the iodinated radiographic contrast media type, final covariates were those selected by using the stepwise method in a logistic regression model. Adjusted relative risks were then estimated by using a log-link regression model. RESULTS Of baseline or endovascular therapy variables potentially linked to outcome, prior antiplatelet agent use was more common and microcatheter iodinated radiographic contrast media injections were fewer with iodixanol. Relative risk point estimates are in favor of iodixanol for the 5 prespecified end points with M1 occlusion. The percentage of risk differences are numerically greater for microcatheter injections with iodixanol. CONCLUSIONS While data favoring the use of iso-osmolal iodixanol for reperfusion of M1 occlusion following IV rtPA are inconclusive, potential pathophysiologic mechanisms suggesting clinical benefit warrant further investigation.
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Affiliation(s)
- T A Tomsick
- From the Department of Radiology (T.A.T., J.C., H.M.), University of Cincinnati Academic Health Center, University Hospital, Cincinnati, Ohio
| | - L D Foster
- Department of Public Health Sciences (L.D.F., Y.Y.P., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
| | - D S Liebeskind
- University of California, Los Angeles Stroke Center (D.S.L.), Los Angeles, California
| | - M D Hill
- Department of Radiology and Clinical Neurosciences (M.D.H., M.G.)
| | - J Carrozella
- From the Department of Radiology (T.A.T., J.C., H.M.), University of Cincinnati Academic Health Center, University Hospital, Cincinnati, Ohio
| | - M Goyal
- Department of Radiology and Clinical Neurosciences (M.D.H., M.G.)
| | | | - A M Demchuk
- Calgary Stroke Program (A.M.D.), Department of Clinical Neurosciences/Medicine/Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - I Dzialowski
- Department of Neurology (I.D.), Elblandklinikum Meissen, Academic Teaching Hospital of Universitätsklinikum, Carl Gustav Carus Technische Universität Dresden, Meißen, Germany
| | - V Puetz
- Neurology (V.P.), Dresden University Stroke Center, Universitätsklinikum Carl Gustav Carus Technischen Universität Dresden, Dresden, Germany
| | - T Jovin
- The Stroke Institute (T.J.), University of Pittsburgh Medical Center, Pittsburgh. Pennsylvania
| | - H Morales
- From the Department of Radiology (T.A.T., J.C., H.M.), University of Cincinnati Academic Health Center, University Hospital, Cincinnati, Ohio
| | - Y Y Palesch
- Department of Public Health Sciences (L.D.F., Y.Y.P., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
| | - J Broderick
- Department of Neurology (J.B., P.K.), University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - P Khatri
- Department of Neurology (J.B., P.K.), University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - S D Yeatts
- Department of Public Health Sciences (L.D.F., Y.Y.P., S.D.Y.), Medical University of South Carolina, Charleston, South Carolina
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Renú A, Amaro S, Laredo C, Román LS, Llull L, Lopez A, Urra X, Blasco J, Oleaga L, Chamorro Á. Relevance of blood-brain barrier disruption after endovascular treatment of ischemic stroke: dual-energy computed tomographic study. Stroke 2015; 46:673-9. [PMID: 25657188 DOI: 10.1161/strokeaha.114.008147] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Computed tomographic (CT) high attenuation (HA) areas after endovascular therapy for acute ischemic stroke are a common finding indicative of blood-brain barrier disruption. Dual-energy CT allows an accurate differentiation between HA areas related to contrast staining (CS) or to brain hemorrhage (BH). We sought to evaluate the prognostic significance of the presence of CS and BH after endovascular therapy. METHODS A prospective cohort of 132 patients treated with endovascular therapy was analyzed. According to dual-energy CT findings, patients were classified into 3 groups: no HA areas (n=53), CS (n=32), and BH (n=47). The rate of new hemorrhagic transformations was recorded at follow-up neuroimaging. Clinical outcome was evaluated at 90 days with the modified Rankin Scale (poor outcome, 3-6). RESULTS Poor outcome was associated with the presence of CS (odds ratio [OR], 11.3; 95% confidence interval, 3.34-38.95) and BH (OR, 10.4; 95% confidence interval, 3.42-31.68). The rate of poor outcome despite complete recanalization was also significantly higher in CS (OR, 9.7; 95% confidence interval, 2.55-37.18) and BH (OR, 15.1; 95% confidence interval, 3.85-59.35) groups, compared with the no-HA group. Patients with CS disclosed a higher incidence of delayed hemorrhagic transformation at follow-up (OR, 4.5; 95% confidence interval, 1.22-16.37) compared with no-HA patients. CONCLUSIONS Blood-brain barrier disruption, defined as CS and BH on dual-energy CT, was associated with poor clinical outcomes in patients with stroke treated with endovascular therapies. Moreover, isolated CS was associated with delayed hemorrhagic transformation. These results support the clinical relevance of blood-brain barrier disruption in acute stroke.
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Affiliation(s)
- Arturo Renú
- From the Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, University of Barcelona, August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., S.A., C.L., L.L., X.U., Á.C.); and Radiology Department, Hospital Clinic, Barcelona, Spain (L.S.R., A.L., J.B., L.O.)
| | - Sergio Amaro
- From the Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, University of Barcelona, August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., S.A., C.L., L.L., X.U., Á.C.); and Radiology Department, Hospital Clinic, Barcelona, Spain (L.S.R., A.L., J.B., L.O.)
| | - Carlos Laredo
- From the Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, University of Barcelona, August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., S.A., C.L., L.L., X.U., Á.C.); and Radiology Department, Hospital Clinic, Barcelona, Spain (L.S.R., A.L., J.B., L.O.)
| | - Luis San Román
- From the Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, University of Barcelona, August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., S.A., C.L., L.L., X.U., Á.C.); and Radiology Department, Hospital Clinic, Barcelona, Spain (L.S.R., A.L., J.B., L.O.)
| | - Laura Llull
- From the Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, University of Barcelona, August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., S.A., C.L., L.L., X.U., Á.C.); and Radiology Department, Hospital Clinic, Barcelona, Spain (L.S.R., A.L., J.B., L.O.)
| | - Antonio Lopez
- From the Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, University of Barcelona, August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., S.A., C.L., L.L., X.U., Á.C.); and Radiology Department, Hospital Clinic, Barcelona, Spain (L.S.R., A.L., J.B., L.O.)
| | - Xabier Urra
- From the Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, University of Barcelona, August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., S.A., C.L., L.L., X.U., Á.C.); and Radiology Department, Hospital Clinic, Barcelona, Spain (L.S.R., A.L., J.B., L.O.)
| | - Jordi Blasco
- From the Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, University of Barcelona, August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., S.A., C.L., L.L., X.U., Á.C.); and Radiology Department, Hospital Clinic, Barcelona, Spain (L.S.R., A.L., J.B., L.O.)
| | - Laura Oleaga
- From the Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, University of Barcelona, August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., S.A., C.L., L.L., X.U., Á.C.); and Radiology Department, Hospital Clinic, Barcelona, Spain (L.S.R., A.L., J.B., L.O.)
| | - Ángel Chamorro
- From the Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic, University of Barcelona, August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain (A.R., S.A., C.L., L.L., X.U., Á.C.); and Radiology Department, Hospital Clinic, Barcelona, Spain (L.S.R., A.L., J.B., L.O.).
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