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Improved Turnaround Times | Median time to first decision: 12 days

Research ArticleNeurointervention

Incidence, Risk Factors, and Clinical Implications of Subarachnoid Hyperdensities on Flat-Panel Detector CT following Mechanical Thrombectomy in Patients with Anterior Circulation Acute Ischemic Stroke

Bettina L. Serrallach, Mattia Branca, Adnan Mujanovic, Anna Boronylo, Julie M. Hanke, Arsany Hakim, Sara Pilgram-Pastor, Eike I. Piechowiak, Jan Gralla, Thomas Meinel, Johannes Kaesmacher and Tomas Dobrocky
American Journal of Neuroradiology July 2024, DOI: https://doi.org/10.3174/ajnr.A8277
Bettina L. Serrallach
aFrom the Department of Diagnostic and Interventional Neuroradiology (B.L.S., A.M., A.B., A.H., S.P.-P., E.I.P., J.G., J.K., T.D.), Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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Mattia Branca
bDepartment of Clinical Research (M.B.), CTU Bern, University of Bern, Bern, Switzerland
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Adnan Mujanovic
aFrom the Department of Diagnostic and Interventional Neuroradiology (B.L.S., A.M., A.B., A.H., S.P.-P., E.I.P., J.G., J.K., T.D.), Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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Anna Boronylo
aFrom the Department of Diagnostic and Interventional Neuroradiology (B.L.S., A.M., A.B., A.H., S.P.-P., E.I.P., J.G., J.K., T.D.), Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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Julie M. Hanke
cDepartment of Neurology (J.M.H., T.M.), Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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Arsany Hakim
aFrom the Department of Diagnostic and Interventional Neuroradiology (B.L.S., A.M., A.B., A.H., S.P.-P., E.I.P., J.G., J.K., T.D.), Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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Sara Pilgram-Pastor
aFrom the Department of Diagnostic and Interventional Neuroradiology (B.L.S., A.M., A.B., A.H., S.P.-P., E.I.P., J.G., J.K., T.D.), Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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Eike I. Piechowiak
aFrom the Department of Diagnostic and Interventional Neuroradiology (B.L.S., A.M., A.B., A.H., S.P.-P., E.I.P., J.G., J.K., T.D.), Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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Jan Gralla
aFrom the Department of Diagnostic and Interventional Neuroradiology (B.L.S., A.M., A.B., A.H., S.P.-P., E.I.P., J.G., J.K., T.D.), Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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Thomas Meinel
cDepartment of Neurology (J.M.H., T.M.), Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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Johannes Kaesmacher
aFrom the Department of Diagnostic and Interventional Neuroradiology (B.L.S., A.M., A.B., A.H., S.P.-P., E.I.P., J.G., J.K., T.D.), Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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Tomas Dobrocky
aFrom the Department of Diagnostic and Interventional Neuroradiology (B.L.S., A.M., A.B., A.H., S.P.-P., E.I.P., J.G., J.K., T.D.), Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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Article Figures & Data

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  • FIG 1.
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    FIG 1.

    Examples of SH grades I to IV. A, SH grade I with hyperdensities in 2 neighboring sulci. B, SH grade II with hyperdensities in >2 neighboring sulci but confinement to 1 lobar area. C, SH grade III with diffuse sulcal hyperdensities affecting >2 lobes. D, SH grade IV with diffuse hyperdensities affecting >2 lobes and intraventricular extension.

  • FIG 2.
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    FIG 2.

    Flow chart depicting patient selection process.

  • FIG 3.
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    FIG 3.

    Baseline intracranial occlusion site (LVO, MVO, and DVO) stratified by SH.

  • FIG 4.
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    FIG 4.

    A, Distribution of mRS scores at 90 days for patients without SH and patients with SH I–IV on FDCT. B, The association of different grades of SH 0–IV with mRS at 3 months, mRS dichotomized (0–2 versus 3–6), and mortality (equivalent to mRS 6). Analyses were performed using multivariable ordinal/logistic regression, adjusting for prespecified confounders (see Materials and Methods).

  • FIG 5.
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    FIG 5.

    Possible mechanism leading to SH. A, Ventrolateral view of the brain and circle of Willis. B, Close-up showing a proximal M2 occlusion with an inserted stent retriever. C, Close-up during the retrieval of the stent retriever. During navigation, smaller vessels (M2 and beyond) tend to straighten more than proximal vessels. The perforators are exposed to excessive forces during thrombectomy due to stretching and may be sheared off, leading to subtle extravasation, which is occult on standard DSA but may be detected on FDCT as SH, in this case, a subarachnoid hemorrhage. © Inselspital, Bern University Hospital, Department of Neuroradiology.

Tables

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    Table 1:

    Baseline characteristics stratified by SH seen on FDCT

    Total NaSH 0–IVTotal NaSH 0Total NaSH I–IVP Value
    Baseline characteristics
     Age (median) [lq, uq]22375.5 [63.3–83.1]12377.6 [63.7–85.0]10074.5 [63.3–82.1].24
     Sex (male), No. (%)223110 (49.3%)12365 (52.8%)10045 (45.0%).24
     Hypertension, No. (%)223164 (73.5%)12393 (75.6%)10071 (71.0%).44
     Diabetes mellitus, No. (%)22350 (22.4%)12331 (25.2%)10019 (19.0%).27
     Coronary heart disease, No. (%)22330 (13.5%)12318 (14.6%)10012 (12.0%).57
     Smoking (current), No. (%)22349 (22.0%)12330 (24.4%)10019 (19.0%).33
     Hyperlipidemia, No. (%)223131 (58.7%)12371 (57.7%)10060 (60.0%).73
     Atrial fibrillation, No. (%)22377 (34.5%)12348 (39.0%)10029 (29.0%).12
     NIHSS at baseline (median) [lq, uq]21912.0 [5.0–20.0]12113.0 [6.0–19.0]9811.0 [5.0–20.0].37
     mRS (prestroke) (median) [lq, uq]2120.0 [0.0–1.0]1180.0 [0.0–1.0]940.0 [0.0– 1.0].66
     Baseline intracranial occlusion site, No. (%)223123100<.001
     LVO114 (51.1%)76 (61.8%)38 (38.0%)
     Medium- and distal- vessel occlusion109 (48.9%)47 (38.2%)62 (62.0%)
    ASPECTS (median) [lq, uq]2207.0 [6.0–9.0]1227.0 [5.0–9.0]987.0 [6.0–9.0].45
    IV thrombolysis, No. (%)223101 (45.3%)12349 (39.8%)10052 (52.0%).07
    Time of symptom onset known, No. (%)223123100.44
     No59 (26.5%)34 (27.6%)25 (25.0%)
     Wake up40 (17.9%)25 (20.3%)15 (15.0%)
     Yes124 (55.6%)64 (52.0%)60 (60.0%)
    Onset-to-groin puncture (median) (lq, uq) (min)223192.0 [155.0–266.0]123186.0 [156.5–266.0]100202.5 [150.0–264.0].99
    Medications (prestroke)
     Antihypertensives, No. (%)220130 (59.1%)12076 (63.3%)10054 (54.0%).16
     Lipid-lowering drugs, No. (%)22370 (31.4%)12340 (32.5%)10030 (30.0%).69
     Anticoagulation, No. (%)22344 (19.7%)12328 (22.8%)10016 (16.0%).21
     Antiplatelet, No. (%)22347 (21.1%)12324 (19.5%)10023 (23.0%).53
    • Note:—lq indicates lower quartile; uq, upper quartile.

    • ↵a N indicates number of patients without missing data.

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    Table 2:

    Procedural characteristics and outcome measures stratified by SH seen on FDCT

    Total NaSH 0–IVTotal NaSH 0Total NaSH I–IVP Value
    Procedural characteristics
     No. of passes, (median) [lq, uq]2182.0 [1.0–3.0]1211.0 [1.0–2.0]972.0 [1.0–4.0]<.001
     Most distal device position, No. (%)223123100<.001
      Large vessel34 (15.2%)30 (24.4%)4 (4.0%)
      Medium vessel140 (62.8%)72 (58.5%)68 (68.0%)
      Distal vessel49 (22.0%)21 (17.1%)28 (28.0%)
     Amount of contrast medium (mL) (median) [lq, uq]217120 [100–180]119110 [90–160]98133 [100–190].035
     Active extravasation seen on DSA, No. (%)22313 (5.8%)1230 (0.0%)10013 (13.0%)<.001
     Parenchymal hyperdensities on FDCT, No. (%)223110 (49.3%)12367 (54.5%)10043 (43.0%).09
     eTICI score, No. (%)22112398.014
      014 (6.3%)3 (2.4%)11 (11.2%)
      14 (1.8%)1 (0.8%)3 (3.1%)
      2a8 (3.6%)6 (4.9%)2 (2.0%)
      2b5028 (12.7%)13 (10.6%)15 (15.3%)
      2b6736 (16.3%)16 (13.0%)20 (20.4%)
      2c50 (22.6%)32 (26.0%)18 (18.4%)
      381 (36.7%)52 (42.3%)29 (29.6%)
    Outcome measures
     mRS at 3 months, (median) [lq, uq]1963.0 [1.0–6.0]1072.0 [1.0–5.0]893.0 [1.0–6.0].21
     NIHSS at 24 hours (median) [lq, uq]2138.0 [3.0–16.0]1208.0 [3.0–16.0]936.0 [3.0–15.0].76
    • Note:—lq indicates lower quartile; uq, upper quartile.

    • ↵a N indicates number of patients without missing data.

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Incidence, Risk Factors, and Clinical Implications of Subarachnoid Hyperdensities on Flat-Panel Detector CT following Mechanical Thrombectomy in Patients with Anterior Circulation Acute Ischemic Stroke
Bettina L. Serrallach, Mattia Branca, Adnan Mujanovic, Anna Boronylo, Julie M. Hanke, Arsany Hakim, Sara Pilgram-Pastor, Eike I. Piechowiak, Jan Gralla, Thomas Meinel, Johannes Kaesmacher, Tomas Dobrocky
American Journal of Neuroradiology Jul 2024, DOI: 10.3174/ajnr.A8277
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Bettina L. Serrallach, Mattia Branca, Adnan Mujanovic, Anna Boronylo, Julie M. Hanke, Arsany Hakim, Sara Pilgram-Pastor, Eike I. Piechowiak, Jan Gralla, Thomas Meinel, Johannes Kaesmacher, Tomas Dobrocky
Incidence, Risk Factors, and Clinical Implications of Subarachnoid Hyperdensities on Flat-Panel Detector CT following Mechanical Thrombectomy in Patients with Anterior Circulation Acute Ischemic Stroke
American Journal of Neuroradiology Jul 2024, DOI: 10.3174/ajnr.A8277

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