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Research ArticleAdult Brain

Iodine Extravasation Quantification on Dual-Energy CT of the Brain Performed after Mechanical Thrombectomy for Acute Ischemic Stroke Can Predict Hemorrhagic Complications

M. Bonatti, F. Lombardo, G.A. Zamboni, F. Vittadello, R. Currò Dossi, B. Bonetti, R. Pozzi Mucelli and G. Bonatti
American Journal of Neuroradiology January 2018, DOI: https://doi.org/10.3174/ajnr.A5513
M. Bonatti
aFrom the Departments of Radiology (M.B., F.L., G.B.)
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F. Lombardo
aFrom the Departments of Radiology (M.B., F.L., G.B.)
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G.A. Zamboni
cDepartment of Radiology (G.A.Z., R.P.M.), University of Verona, Verona, Italy
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F. Vittadello
dExplora-Research and Statistical Analysis (F.V.), Vigodarzere, Italy.
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R. Currò Dossi
bNeurology (R.C.D., B.B.), Bolzano Central Hospital, Bolzano, Italy
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B. Bonetti
bNeurology (R.C.D., B.B.), Bolzano Central Hospital, Bolzano, Italy
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R. Pozzi Mucelli
cDepartment of Radiology (G.A.Z., R.P.M.), University of Verona, Verona, Italy
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G. Bonatti
aFrom the Departments of Radiology (M.B., F.L., G.B.)
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  • Fig 1.
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    Fig 1.

    A, Postoperative DECT with an iodine map overlay shows a cortical-subcortical hyperdensity secondary to iodine extravasation with a maximum iodine concentration of 3.0 mg/mL; no hyperdensity was visible on virtual unenhanced images (not included). B, A follow-up CT performed 48 hours later because of sudden clinical worsening shows a large parenchymal hematoma with a contralateral shift of the midline structures.

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    Fig 2.

    A, Postoperative DECT with an iodine map overlay shows a cortical-subcortical and deep white matter hyperdensity secondary to iodine extravasation with a maximum iodine concentration of 1.2 mg/mL; no hyperdensity was visible on virtual unenhanced images (not included). B, The follow-up CT performed before discharge, 4 days later, shows ischemic lesions at the sites of iodine extravasation but no hemorrhage.

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    Fig 3.

    Receiver operator characteristic (ROC) curve showing sensitivity and specificity of maximum hyperdensity attenuation in identifying patients developing ICH.

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    Fig 4.

    Receiver operator characteristic (ROC) curve showing sensitivity and specificity of maximum iodine concentration in identifying patients developing ICH.

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    Fig 5.

    Graph showing the linear correlation existing between maximum hyperdensity attenuation and maximum iodine concentration.

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    Fig 6.

    Diagnostic algorithm that enables identifying patents developing ICH with 100% sensitivity and 67.6% specificity.

Tables

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    Table 1:

    Scanning parameters for postoperative unenhanced dual-energy brain CT and follow-up unenhanced brain CT

    DECTSECT
    Scanning techniqueSpiralSpiral
    Scan directionCaudocranialCaudocranial
    kVp80/140120
    mAs ref310/155390
    Collimation (mm)40 × 0.6128 × 0.6
    Rotation time (sec)0.51
    Pitch0.70.55
    CARE Dose 4DaOnOn
    CARE-kVaNot availableOff
    X-CAREaNot availableOn
    KernelD34fH40s
    • Note:—SECT indicates single-energy CT; ref, reference.

    • ↵a Siemens.

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    Table 2:

    Results of postoperative DECT image analysis with interreader concordance and subsequent consensus

    Reader 1Reader 2Interreader ConcordanceConsensus
    Presence of parenchymal hyperdensity
        Yes53/85 (62.4%)53/85 (62.4%)κ = 0.95; 95% CI, 0.882–1.00054/85 (63.5%)
        No32/85 (37.6%)32/85 (37.6%)31/85 (36.5%)
    Hyperdensity location
        DWM26/53 (49.1%)31/53 (58.5%)κ = 0.745; 95% CI, 0.588–0.90329/54 (53.7%)
        DWM+cortical/subcortical21/53 (39.6%)16/53 (30.2%)18/54 (33.3%)
        Cortical/subcortical6/53 (11.3%)6/53 (11.3%)7/54 (13.0%)
    Hyperdensity homogeneity
        Homogeneous29/53 (54.7%)31/53 (58.5%)κ = 0.799; 95% CI, 0.632–0.96630/54 (55.6%)
        Inhomogeneous24/53 (45.3%)22/53 (41.5%)24/54 (44.4%)
    Mean maximum attenuation (HU)100 (median 77, range 45–701)103 (median 76, range 47–789)P = .99974 (range, 47–745)
    Presence of iodine extravasation
        Yes53/85 (62.4%)53/85 (62.4%)κ = 0.976; 95% CI, 0.929–1.00054/85 (63.5%)
        No32/85 (37.6%)32/85 (37.6%)31/85 (36.5%)
    Mean maximum iodine concentration (mg/dL)3.0 (median,1.8; range 0.5–28.4)2.9 (median, 1.6; range 0.6–27.7)P = .9261.8 (range, 0.5–28.1)
    Hemorrhage on VNC images
        Yes5/85 (5.9%)5/85 (5.9%)κ = 1.000; 95% CI, 1.000–1.0005/85 (5.9%)
        No80/85 (94.1%)80/85 (94.1%)80/85 (94.1%)
    • Note:—DWM indicates deep white matter.

    • View popup
    Table 3:

    Univariate analysis—association between postoperative dual-energy CT parameters and subsequent intracerebral hemorrhage developmenta

    Non-ICH Group (n = 71)ICH Group (n = 14)P Value
    No. (%)No. (%)
    Hyperdensity on simulated 120-kV images.002b
        Yes40/71 (56.3%)14/14 (100%)
        No31/71 (43.7%)0/14 (0%)
    Hyperdensity site.342
        DWM23/40 (57.5%)6/14 (42.9%)
        DWM + cortical11/40 (27.5%)7/14 (50.0%)
        Cortical6/40 (15.0%)1/14 (7.1%)
    Hyperdensity homogeneity.028b
        Homogeneous26/40 (65.0%)4/14 (28.6%)
        Inhomogeneous14/40 (35.0%)10/14 (71.4%)
    Hyperdensity maximum attenuation.010b
        Median (HU)6885
    Iodine extravasation on iodine map images.002b
        Yes40/71 (56.3%)14/14 (100%)
        No31/71 (43.7%)0/14 (0%)
    Maximum iodine concentration<.001b
        Median (mg/mL)1.402.63
    Hemorrhage on VNC images<.001b
        Yes0/71 (0%)5/14 (35.7%)
        No71/71 (100%)9/14 (64.3%)
    • Note:—DWM indicates deep white matter.

    • ↵a The strength of the association is quantified by the P value (significant if P < .05).

    • ↵b Significant.

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Iodine Extravasation Quantification on Dual-Energy CT of the Brain Performed after Mechanical Thrombectomy for Acute Ischemic Stroke Can Predict Hemorrhagic Complications
M. Bonatti, F. Lombardo, G.A. Zamboni, F. Vittadello, R. Currò Dossi, B. Bonetti, R. Pozzi Mucelli, G. Bonatti
American Journal of Neuroradiology Jan 2018, DOI: 10.3174/ajnr.A5513
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  • Determinants and Clinical Relevance of Iodine Contrast Extravasation after Endovascular Thrombectomy: A Dual-Energy CT Study
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  • Prediction of Hemorrhage after Successful Recanalization in Patients with Acute Ischemic Stroke: Improved Risk Stratification Using Dual-Energy CT Parenchymal Iodine Concentration Ratio Relative to the Superior Sagittal Sinus
  • Quantification of Iodine Leakage on Dual-Energy CT as a Marker of Blood-Brain Barrier Permeability in Traumatic Hemorrhagic Contusions: Prediction of Surgical Intervention for Intracranial Pressure Management
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M. Bonatti, F. Lombardo, G.A. Zamboni, F. Vittadello, R. Currò Dossi, B. Bonetti, R. Pozzi Mucelli, G. Bonatti
Iodine Extravasation Quantification on Dual-Energy CT of the Brain Performed after Mechanical Thrombectomy for Acute Ischemic Stroke Can Predict Hemorrhagic Complications
American Journal of Neuroradiology Jan 2018, DOI: 10.3174/ajnr.A5513

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