[논문]Leak Sign on Dynamic-Susceptibility-Contrast Magnetic Resonance Imaging in Acute Intracerebral Hemorrhage

Park, Ji Kang; Hong, Dae Young; Jin, Sun Tak; Lee, Dong-Woo; Pyun, Hae Wook

doi:10.13104/imri.2020.24.3.154

[국내논문] Leak Sign on Dynamic-Susceptibility-Contrast Magnetic Resonance Imaging in Acute Intracerebral Hemorrhage 원문보기

Investigative magnetic resonance imaging, v.24 no.3, 2020년, pp.154 - 161

Park, Ji Kang (Department of Radiology, Pohang Stroke and Spine Hospital) , Hong, Dae Young (Department of Neurosurgery, Pohang Stroke and Spine Hospital) , Jin, Sun Tak (Department of Neurosurgery, Pohang Stroke and Spine Hospital) , Lee, Dong-Woo (Department of Neurosurgery, Pohang Stroke and Spine Hospital) , Pyun, Hae Wook (Department of Radiology, Pohang Stroke and Spine Hospital)

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Purpose: A CT angiography spot sign (CTA-spot) is a significant predictor of the early expansion of an intracerebral hemorrhage (ICH-Ex). Dynamic-susceptibility-contrast magnetic resonance imaging (DSC-MRI) can track the real-time leaking of contrast agents. It may be able to indicate active bleeding, like a CTA-spot. Materials and Methods: From September 2014 to February 2017, we did non-contrast CT, CTA, and DSC-MRI examinations of seven patients with acute ICH. We investigated the time from symptom onset to the first contrast-enhanced imaging. We evaluated the time course of the contrast leak within the ICH at the source image of the DSC-MRI and the volume change of ICH between non-contrast CT and DSC-MRI. We compared the number of slices showing CTA-spots and DSC-MRI leaks. Results: The CTA-spot and DSC-MRI leak-sign were present in four patients, and two patients among those showed ICH-Ex. The time from the symptom onset to CTA or DSC-MRI was shorter for those with a DSC-MRI leak or CTA-spot than for three patients without either (70-130 minutes vs. 135-270 minutes). The leak-sign began earlier, lasted longer, and spread to more slices in the patients with ICH-Ex than in those without ICH-Ex. The number of slices of the DSC-MRI leak and the number of the CTA-spot were well correlated. Conclusion: DSC-MRI can demonstrate the leakage of GBCA within hyperacute ICH, showing the good contrast between hematoma and contrast. The DSC-MRI leakage sign could be related to the hematoma expansion in patients with ICH.

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가설 설정

An 86-year-old patient with ICH-Ex. (a, b) Initial DWI and GRE were showing acute ICH (18.2 mL) in the right basal ganglia. The ICH significantly increased (71.

제안 방법

We investigated the time from symptom onset to the first contrast-enhanced imaging (TTI). A radiologist evaluated the location, change of ICH volume, and features of a CTA-spot sign or DSC-MRI leak sign. ICH volumes were calculated on the initial CT and follow-up CT and T2*- GRE with the previously validated ABC/2 method (13).
We recently worked with seven patients with hyperacute ICH, which was evaluated by DSC-MRI. In this paper, we describe the clinical profile and imaging findings of DSCMRI in the seven patients, and we evaluated whether DSCMRI could detect active bleeding with ICH.
Precontrast and postcontrast CT were obtained with a 5-mm slice thickness without a gap. MRI was done with a 1.5 T scanner (Achieva, Philips Medical System, Best, the Netherlands) in six subjects, and with a 3.0 T scanner (Ingenia Q, Philips) in one subject. Our stroke MRI protocol was done with diffusion-weighted-imaging (DWI), DSC-MRI, FLAIR, T2*-gradient-recalled-echo (GRE), or susceptibility-weighted-imaging (SWI).
Since our study was a small case series, we need more clinical experience using DSC-MRI for detecting the spot sign in acute ICH, and further imaging sequences such as CE-T1 may be required to complement DSC-MRI, especially if TTI is more delayed than 4-6 hours when ICH may have dark SI on DSC-MRI. In T1WI, hyperacute ICH usually has iso-SI, and a GBCA leak may appear as a bright spot on CE-T1 (9-12).

이론/모형

A radiologist evaluated the location, change of ICH volume, and features of a CTA-spot sign or DSC-MRI leak sign. ICH volumes were calculated on the initial CT and follow-up CT and T2*- GRE with the previously validated ABC/2 method (13). We evaluated the volume change of ICH between first precontrast CT and T2*-GRE.

성능/효과

5 in these patients. In patients without ICH-Ex, the DSC-MRI leak was found in 1 slice, and the CTA-spot number was 2. The mean number of microbleeds was 21 in two patients with ICH-Ex and 6.8 in five patients without ICH-Ex. The 3-month mRS score was 5 for two patients with ICH-Ex and median 3 (3-5) for patients without ICH-Ex.
In conclusion, our case series demonstrated a real-time GBCA leak within hyperacute ICH with the use of DSC-MRI. Although MRI has limitations for severely ill patients, DSCMRI may be an option for detecting the leakage of GBCA within hyperacute ICH.
To improve the sensitivity of the CTA-spot sign, different CT techniques, such as the delayed post-contrast CT, perfusion CT, and dynamic CTA, have been used (5-8). In their studies, the CT techniques improved the detection of contrast leakage within a hematoma and increased the sensitivity to approximately 90%. According to the results of dynamic CTA and perfusion CT, the median time for the peak CTAspot attenuation was 30.

참고문헌 (14)

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Demchuk AM, Dowlatshahi D, Rodriguez-Luna D, et al. Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign (PREDICT): a prospective observational study. Lancet Neurol 2012;11:307-314

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Wada R, Aviv RI, Fox AJ, et al. CT angiography "spot sign" predicts hematoma expansion in acute intracerebral hemorrhage. Stroke 2007;38:1257-1262

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Chakraborty S, Alhazzaa M, Wasserman JK, et al. Dynamic characterization of the CT angiographic 'spot sign'. PLoS One 2014;9:e90431

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Ederies A, Demchuk A, Chia T, et al. Postcontrast CT extravasation is associated with hematoma expansion in CTA spot negative patients. Stroke 2009;40:1672-1676

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Koculym A, Huynh TJ, Jakubovic R, Zhang L, Aviv RI. CT perfusion spot sign improves sensitivity for prediction of outcome compared with CTA and postcontrast CT. AJNR Am J Neuroradiol 2013;34:965-970, S961

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Schindlbeck KA, Santaella A, Galinovic I, et al. Spot sign in acute intracerebral hemorrhage in dynamic T1-weighted magnetic resonance imaging. Stroke 2016;47:417-423

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Aviv RI, Huynh T, Huang Y, et al. An in vivo, MRI-integrated real-time model of active contrast extravasation in acute intracerebral hemorrhage. AJNR Am J Neuroradiol 2014;35:1693-1699

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Murai Y, Matano F, Morita A. MRI punctate sign and CTA spot sign for primary intracerebral hemorrhage. Neurologist 2020;25:17

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Kothari RU, Brott T, Broderick JP, et al. The ABCs of measuring intracerebral hemorrhage volumes. Stroke 1996;27:1304-1305

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Rodriguez-Luna D, Coscojuela P, Rodriguez-Villatoro N, et al. Multiphase CT angiography improves prediction of intracerebral hemorrhage expansion. Radiology 2017;285:932-940

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[국내논문] Leak Sign on Dynamic-Susceptibility-Contrast Magnetic Resonance Imaging in Acute Intracerebral Hemorrhage 원문보기

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[국내논문] Leak Sign on Dynamic-Susceptibility-Contrast Magnetic Resonance Imaging in Acute Intracerebral Hemorrhage 원문보기

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