title: Intracranial extravasation of contrast medium during diagnostic CT angiography in the initial evaluation of subarachnoid hemorrhage: report of 16 cases and review of the literature.
abstract: BACKGROUND
  Three-dimensional CT angiography (3D-CTA) is increasingly used in the initial evaluation of subarachnoid hemorrhage (SAH). However, there is a risk of aneurysm re-rupture in the hyperacute phase. We sought to clarify the incidence of re-rupture and characterize the subgroup in which extravasation of contrast media was seen on 3D-CTA.
  
  
  METHODS
  We examined the records of 356 consecutive patients presenting to our institution with non-traumatic SAH between October 2003 and December 2011. After resuscitation, patients with poor grade SAH underwent CT then 3D-CTA while sedated, mechanically ventilated and with a target systolic blood pressure of 120 mmHg.
  
  
  RESULTS
  336 patients underwent 3D-CTA; 20 died without return of spontaneous circulation. Extravasated contrast medium was seen in 16 (4.8%), 15 (4.5%) at the initial evaluation. Their World Federation of Neurosurgical Societies Grade was V; one patient was resuscitated from cardiac arrest. The mean times from onset to arrival and to CTA were 43.7 minutes and 71.8 minutes, respectively. Ten patients (62.5%) had episodes suggestive of aneurysm re-rupture before 3D-CTA. Surgical clipping, evacuation of hematoma and wide decompressive craniectomy was completed in six patients and one underwent coil embolization. Two of 16 patients survived: one with moderate disability and one made a good recovery.
  
  
  CONCLUSIONS
  Contrast extravasation was detected by 3D-CTA in 4.5% of cases despite intensive resuscitation, suggesting that continuous or intermittent rebleeding may occur frequently in the hyperacute phase. The consequences of rebleeding are devastating; however, favorable results can be obtained with immediate aneurysm repair with decompression and intensive neurocritical care.
authors.affiliation: Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan ; 11-1 Minamiakutagawacho, Takatsuki, Osaka, 569-1124 Japan.
authors.forename: Hitoshi
authors.initials: H
authors.lastname: Kobata
authors.forename: Akira
authors.initials: A
authors.lastname: Sugie
authors.forename: Erina
authors.initials: E
authors.lastname: Yoritsune
authors.forename: Tomo
authors.initials: T
authors.lastname: Miyata
authors.forename: Taichiro
authors.initials: T
authors.lastname: Toho
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