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| NEUROIMAGE |
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| Year : 2022 | Volume
: 70
| Issue : 2 | Page : 830-831 |
“Pseudo” Subarachnoid Hemorrhage on FDCT in Endovascular Procedures: A New Dilemma
Chirag Jain, Manish Chugh
Department of Neurointervention Radiology, Division of Neurosciences, Sir Ganga Ram Hospital, New Delhi, India
| Date of Submission | 23-Jan-2021 |
| Date of Decision | 29-Jan-2021 |
| Date of Acceptance | 12-Apr-2021 |
| Date of Web Publication | 3-May-2022 |
Correspondence Address:
Dr. Chirag Jain
5th Floor, Department of Neurointervention Radiology, SGRH, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.344598
How to cite this article:
Jain C, Chugh M. “Pseudo” Subarachnoid Hemorrhage on FDCT in Endovascular Procedures: A New Dilemma. Neurol India 2022;70:830-1 |
A 55-year female with multiple intracranial aneurysms, previously managed by coiling, was planned for elective flow diverter placement of recurred, previously ruptured left ICA aneurysm [Figure 1]a, [Figure 1]b. The patient had no focal neurological deficits. Preprocedure spiral CT scan of head [Figure 3]a showed no hemorrhage or infarct. Under cover of dual antiplatelet agents (Aspirin 150 mg and Prasugrel 10 mg for 5 days), a flow diverter (4.75 × 20 mm) was deployed across the aneurysm [Figure 1]d under general anesthesia. The distal wire was positioned at the M1 segment of the left MCA [Figure 1]c with careful observation at the movement of wire during the entire procedure. At no point of time during the procedure, no interventional hardware was outside the confines of fluoroscopic visualization of normal vasculature. The procedure was uneventful [Figure 2] and the device showed optimum apposition. A postprocedure flat panel detector CT was performed and showed hyperdensity in ipsilateral superior frontal sulcus [Figure 3]b. A repeat CT scan of the head [Figure 3]c, 12 h after the procedure, showed the complete resolution of the hyperdensity. This pseudo-subarachnoid pattern of sulcal hyperdensity in an otherwise uneventful procedure is an uncommon entity[1] with complete, uneventful recovery. It is postulated that this phenomenon occurs from the leakage of contrast as nonionic contrast media may transiently increase the blood–brain barrier permeability.[2],[3] In cases where accurate differentiation between contrast extravasation and haemorrhage is needed, dual-energy CT may be performed for confirmation.[4] Interventionists should be cognizant regarding the benevolent nature of such sulcal hyperdensity which does not require aggressive management. | Figure 1: Digital subtraction angiography images showing the coil mass in the left communicating ICA aneurysm with regrowth at neck (a, arrows), with corresponding three-dimensional rotational angiography images (b). Placement of a flow diverter with the careful positioning of the tip of the wire in the inferior division origin of left MCA (c). Optimum apposition of the flow diverter device in the left internal carotid artery (d)
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 | Figure 2: Postprocedure angiographies in early and late arterial (a and b), parenchymal (c), and venous phases (d) show no complications in form of vascular occlusions or active extravasation
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 | Figure 3: Preoperative CT scan of the head (a) shows no bleed in the sulcal spaces over the cerebral convexity. Postprocedural flat panel detector CT image (b) showing hyperdensity in the left superior frontal sulcus, which completely resolved on 12 h follow-up CT scan of the head (c)
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Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| » References | |  |
| 1. | Shinohara Y, Sakamoto M, Takeuchi H, Uno T, Watanabe T, Kaminou T, et al. Subarachnoid hyperattenuation on flat panel detector–Based conebeam CT immediately after uneventful coil embolization of unruptured intracranial aneurysms. AJNR Am J Neuroradiol 2013;34:577-82.  |
| 2. | Uchiyama Y, Abe T, Hirohata M, Tanaka N, Kojima K, Nishimura H, et al. Blood brain–barrier disruption of nonionic iodinated contrast medium following coil embolization of a ruptured intracerebral aneurysm. AJNR Am J Neuroradiol 2004;25:1783-6. |
| 3. | Numaguchi Y, Fleming MS, Hasuo K, Puyau FA, Nice Jr CM. Blood-brain barrier disruption due to cerebral arteriography: CT findings. J Comput Assist Tomogr 1984;8:936-9. |
| 4. | Zaouak Y, Sadeghi N, Sarbu N, Ligot N, Lubicz B. Differentiation between cerebral hemorrhage and contrast extravasation using dual energy computed tomography after intra-arterial neuro interventional procedures. J Belg Soc Radiol 2020;104:70. |
[Figure 1], [Figure 2], [Figure 3]
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