Original article
Hyperacute intraventricular hemorrhage: detection and characterization, a comparison between 5 MRI sequencesHémorragie intraventriculaire en phase hyperaiguë : détection et caractérisation à partir de cinq séquences IRM

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Abstract

We aimed to evaluate the diagnostic accuracy of MRI for detecting early intraventricular hemorrhage (IVH) (within 6 hours after hemorrhage and to describe the MR features that allow diagnosis. For this purpose, MR data of 22 patients with hyperacute intraparenchymal hemorrhage were independently rated as negative or positive for IVH by two observers, in a blind, retrospective study taking computed tomography (CT) as providing the correct diagnosis of IVH. Sensitivity, specificity, intra- and interobserver agreement were assessed. On FSE-FLAIR, EPI-GRE-T2* and DWI images, all cases of IVH were correctly rated (sensitivity of 100%). For b0 EPI images, obtained from diffusion-weighted echo planar sequences, one case of IVH was missed by one reader (sensitivity of 88%). For T1 images, one patient was incorrectly rated negative for IVH by the two readers (sensitivity of 90%). Three forms of IVH were described, including clotted hematoma, layered hemorrhage and red blood cell deposit. When CT images were obtained within a time span of less than 3 hours after MRI, volume was assessed. Volume of hemorrhage on CT correlated best with DWI images but was underestimated on EPI-GRE T2* images.

Résumé

Le but de cette étude était d'évaluer les performances diagnostiques de l'IRM dans la détection précoce (six heures) de l'hémorragie intraventriculaire (HIV) et de décrire les critères séméiologiques d'IRM qui permettent son diagnostic. Vingt-deux patients avec hématome intracérébral ont été classés de façon indépendante et à l'aveugle comme présentant ou non une HIV par deux observateurs. Le scanner a été utilisé comme gold standard. La sensibilité, spécificité et évaluation intra- et interobservateur ont été déterminées. En séquence FLAIR, EPI-GRE-T2* et imagerie de diffusion à b1000, toutes les hémorragies intraventriculaires étaient détectées (sensibilité de 100 %). Un cas d'hémorragie intraventriculaire n'a pas été détecté par un lecteur en imagerie de diffusion à b0 (sensibilité de 88 %). En séquence T1, une hémorragie intraventriculaire n'était pas détectée par les deux lecteurs (sensibilité de 90 %). Trois formes d'hémorragie intraventriculaire étaient décrites : caillot, niveau hémorragique et sédiment globulaire. Dans les cas où un scanner était réalisé dans les trois heures suivant l'IRM, l'aspect de l'hématome était comparé. L'image de diffusion s'est avérée la plus proche de celle du scanner. En revanche, la séquence EPI-GRE-T2* sous-estimait notablement le volume de l'hématome.

Introduction

During the last decade, MR imaging has been increasingly used as the primary imaging tool for patients with suspicion of acute stroke. Although CT is still the usual means for detecting early hemorrhage, several studies support the use of early MR imaging for this purpose [1], [8], [12], [14], [16], [17], [18] owing to its high sensitivity for identifying early blood degradation products. Despite the fact that appearance and progression of intraparenchymal hemorrhage (IPH) on MR images have received extensive study over the past several years [2], [3], [6], [7], [9], [10], [11], [15], the appearance of intraventricular blood, within the first few hours, has rarely come to clinical attention. In an early report, Bakshi et al. was the first group to describe two forms of intraventricular hemorrhage (IVH) by MRI, a fixed clot or a free- flowing mixture layering with cerebrospinal fluid (CSF), with or without blood -CSF level [4]. Later, they showed that FLAIR MR imaging was very sensitive to acute and subacute intraventricular hemorrhage [5]. The present study was conducted:

  • to evaluate the sensitivity of MRI in the detection of hyperacute IVH, associated with deep, large hematoma, among 5 different MR sequences, using CT as the gold standard;

  • and to investigate the appearance of intraventricular blood.

We tested the hypothesis that early MR imaging, using a standardized stroke protocol, would be effective and reliable in the diagnosis of hyperacute IVH with high sensitivity and specificity.

Section snippets

Study population

After a retrospective review of the stroke unit reports of our hospital between November 1997 and April 2004, two-hundred and five consecutive patients (N = 205) with acute stroke were identified. Only those with IPH who were referred for MR examination in the setting of acute stroke within 6 hours after symptoms onset and who had a CT-scan within the first 7 days confirming the diagnosis of IVH, without any clinical change or brain surgery, were included. Among the 205 patients considered, only

Results

Twenty-two patients with IPH, eleven of them with IVH, were retrospectively studied. There were 18 males and 4 females patients ranging in age from 51 and 89 years (mean age, 69 years). Sixteen cases involved arterial hypertension; one, arteriovenous malformation; one, low platelets; and four, unknown etiology.

The accuracy of MR for identifying hyperacute IVH is shown in Table 1, Table 2. The results of imaging findings of IVH, analyzing pattern and signal intensitity , are summarized in Table 3

Discussion

In analogy to subarachnoid hemorrhage (SAH), fresh intraventricular blood degrades more slowly than coexisting intraparenchymal hematoma because dilution by CSF and higher local oxygen content [6]. Therefore, recognition of IVH has prognostic value and may help to select patients for interventional therapy to avoid obstructive hydrocephalus. There are only a few studies on MR imaging of hyperacute intraventricular hemorrhage. Bakshi was the first to analyze the MR features of IVH, to describe

Conclusion

MRI seems to be diagnostic in the evaluation of hyperacute intraventricular hemorrhage as a complication of a deep intraparenchymal hematoma and may be of use as a primary diagnostic tool in stroke patient. FSE-FLAIR best performed for detection of clotted and layered hemorrhage and b1000 SE-DWI for quantification. EPI-GRE-T2* significantly underestimated the extent of bleeding when compared to CT. b0 images could not replace GRE images for the detection of acute blood products.

References (18)

  • M.C. Arnould et al.

    Comparison of CT and three MR sequences for detecting and categorizing early (48 hours) hemorraghic transformation in hyperacute ischemic stroke

    AJNR Am. J. Neuroradiol.

    (2004)
  • S. Atlas et al.

    Intracranial hemorrhage: gradient-echo MR imaging at 1.5 T. Comparison with spin-echo imaging and clinical applications

    Radiology

    (1988)
  • S.W. Atlas et al.

    MR detection of hyperacute parenchymal hemorrhage of the brain

    AJNR Am. J. Neuroradiol.

    (1998)
  • R. Bakshi et al.

    MRI in cerebral intraventricular hemorrhage: analysis of 50 consecutive cases

    Neuroradiology

    (1999)
  • R. Bakshi et al.

    Fluid-attenuated inversion-recovery MR imaging in acute and subacute cerebral intraventricular hemorrhage

    AJNR Am. J. Neuroradiol.

    (1999)
  • W.J. Bradley

    MR appearance of hemorrhage in the brain

    Radiology

    (1993)
  • R. Clark et al.

    Acute hematomas: effects of deoxygenation, hematocrit, and fibrin-clot formation and retraction on T2 shortening

    Radiology

    (1990)
  • J.B. Fiebach et al.

    Stroke magnetic resonance imaging is accurate in hyperacute intracerebral hemorrhage. A multicenter study on the validity of stroke imaging

    Stroke

    (2004)
  • J.M. Gomori et al.

    Intracranial hematomas: imaging by high-field MR

    Radiology

    (1985)
There are more references available in the full text version of this article.

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