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AJNR - American Journal of Neuroradiology

Published ahead of print on December 7, 2007
doi: 10.3174/ajnr.A0859

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Contrast Extravasation on CT Predicts Mortality in Primary Intracerebral Hemorrhage

J. Kim^a, A. Smith^a, J.C. Hemphill, III^b, W.S. Smith^b, Y. Lu^a, W.P. Dillon^a and M. Wintermark^a

^a Departments of Radiology, Neuroradiology Section, University of California, San Francisco, San Francisco, Calif
^b Department of Neurology, University of California, San Francisco, San Francisco, Calif

View larger version (17K): [in this window] [in a new window]   Fig 1. Schematic of patient selection for our study. The decision of obtaining a CTA/CECT of the brain immediately following the initial NCCT was made by the neurologist in charge of the patient, on the basis of the degree of suggestion of an underlying origin for the intracranial hemorrhage (ICH). Seventy-six percent (190/250) turned out to have such an underlying cause (aneurysm, vascular malformation, vasculitis, venous infarction, Moyamoya disease, or brain tumor), whereas 24% (60/250) were finally diagnosed with primary ICH. Among the 60 patients with primary ICH, 56 underwent follow-up brain imaging. Among the 4 who did not, 2 died before follow-up imaging. AVM indicates arteriovenous malformation; NCT, noncontrast CT.

View larger version (42K): [in this window] [in a new window]   Fig 2. A 69-year-old man underwent imaging 2 hours following onset of right-sided paralysis. A, Admission NCCT demonstrates left thalamic hematoma with extension of hemorrhage into the third ventricle. Admission CTA (B) and CECT (C), respectively, show 2 foci of active extravasation (arrows). D, Follow-up NCCT 12 hours later shows marked hematoma growth with hemorrhage in both lateral ventricles and severe hydrocephalus. The patient had a fatal outcome.

View larger version (39K): [in this window] [in a new window]   Fig 3. An 82-year-old man underwent imaging 0.5 hours following onset of right-sided weakness. Admission NCCT (A) and CTA (B) demonstrate hemorrhage in the left midbrain without active extravasation on CTA. C, Admission CECT, however, reveals focal high attenuation (arrow) in the left tectal plate, consistent with active extravasation. D, Follow-up NCCT 17 hours later shows hematoma expansion into the left thalamus and lateral ventricle with marked hydrocephalus. The patient had a fatal outcome.

View larger version (35K): [in this window] [in a new window]   Fig 4. An 85-year-old woman underwent imaging 1 hour following onset of left-sided weakness. A, Admission NCCT demonstrates hemorrhage in the right superior frontal gyrus. B, Admission CTA conspicuously reveals a focal area of high attenuation (arrow) within the hematoma consistent with active extravasation. C, Admission CECT shows a slightly heterogeneous right frontal hematoma with several areas of higher attenuation, frequently seen with acute hemorrhage, which were not interpreted by the reviewer as discrete foci of contrast extravasation (as a reminder, the reviewer evaluated CTA and CECT images separately from each other). This patient survived.