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Feb 2012

Contrast Extravasation: A Surrogate Marker of Primary Intracerebral Hemorrhage and Secondary Expansion

Author Affiliations

Author Affiliations: Division of Neuroradiology, Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Huynh and Aviv).

Arch Neurol. 2012;69(2):278. doi:10.1001/archneurol.2011.1213

Jeong et al1 report a patient who developed a hyperacute spontaneous intracerebral hemorrhage during a follow-up magnetic resonance imaging examination to evaluate a previously coiled posterior communicating artery aneurysm. Active contrast extravasation was identified and increased between the 2 postcontrast studies performed 3 minutes apart. This case exemplifies the role of contrast extravasation as a potent surrogate marker of primary hematoma formation. Contrast extravasation within a hematoma on arterial-phase computed tomographic angiography, referred to as the “Spot Sign,” has also been shown to be an important predictor of secondary hematoma expansion and poor clinical outcome.2 Hematomas demonstrating extravasation may undergo dramatic secondary expansion (ie, developing within minutes).3 Although the etiology of primary contrast extravasation is uncertain, it is likely that the causative lesion has the potential for further delayed extravasation, manifest as the Spot Sign. It is notable that, despite initial contrast extravasation, the hematoma did not undergo secondary expansion, with an improvement in the patient's National Institutes of Health Stroke Scale score reported at hospital discharge 4 days later. Smaller hematomas, however, are less likely to undergo secondary hematoma expansion.4 Two studies5,6 evaluating contrast extravasation as a target for recombinant factor VIIa treatment are currently under way and will provide guidance for future management of primary intracerebral hemorrhage. The present case demonstrates the importance of early therapeutic intervention to reduce both primary and secondary expansion.

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