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AJNR - American Journal of Neuroradiology

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American Journal of Neuroradiology 26:1798-1803, August 2005
© 2005 American Society of Neuroradiology

INTERVENTIONAL

Hypoattenuation on CT Angiographic Source Images Predicts Risk of Intracerebral Hemorrhage and Outcome after Intra-Arterial Reperfusion Therapy

Lee H. Schwamm^a, Eric S. Rosenthal^a, Clifford J. Swap^a, Jonathan Rosand^a, Guy Rordorf^a, Ferdinando S. Buonanno^a, Mark G. Vangel^b, Walter J. Koroshetz^a and Michael H. Lev^b

^a Department of Neurology, Massachusetts General Hospital, Boston, MA
^b Department of Radiology, Massachusetts General Hospital, Boston, MA

Author reprint requests to Lee H. Schwamm, Department of Neurology, VBK 915, Massachusetts General Hospital, Boston, MA 02114

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 (HU) calculated. Receiver operator characteristic (ROC) curves and cross-validation were used to identify threshold HU 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 HU (9.0 vs 6.3, P = .006). The ROC threshold at HU 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.

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