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Sulcal Hyperintensity on Fluid-Attenuated Inversion Recovery Imaging in Acute Ischemic Stroke Patients Treated With Intra-Arterial Thrombolysis: Iodinated Contrast Media as Its Possible Cause and the Association With Hemorrhagic Transformation

Kim, Eung Yeop MD*‡; Kim, Sam Soo MD*†; Na, Dong Gyu MD§; Roh, Hong Gee MD*; Ryoo, Jae Wook MD; Kim, Ho Kyun MD

Journal of Computer Assisted Tomography: March-April 2005 - Volume 29 - Issue 2 - p 264-269
doi: 10.1097/01.rct.0000155669.05643.49
Original Article: Neuroimaging

Objective: To investigate the effect of iodinated contrast medium on sulcal hyperintensity on fluid-attenuated inversion recovery (FLAIR) imaging immediately after intra-arterial thrombolysis in patients with acute ischemic stroke and to determine whether it may be associated with subsequent hemorrhagic transformation (HT).

Methods: Fourteen consecutive patients with acute ischemic stroke who were treated with intra-arterial thrombolysis were enrolled. All patients underwent noncontrast computed tomography (NCT) and diffusion-weighted (DWI), perfusion-weighted, gradient-recalled echo (GRE), and gadolinium-enhanced T1-weighted magnetic resonance imaging (MRI). Immediate follow-up NCT and MRI (T2-weighted, FLAIR, GRE, DWI, perfusion-weighted, T1-weighted, and gadolinium-enhanced T1-weighted) were obtained and evaluated to determine the presence of sulcal hyperintensity or subarachnoid hemorrhage (SAH). The same follow-up images were obtained on days 1, 3, and 7 and evaluated to determine HT.

Results: Sulcal hyperintensity was found in 8 (57.1%) of 14 patients and was seen as hyperattenuation on immediate follow-up NCT and as hyperintensity on T1-weighted images in 4 (50%) of 8 patients. It may be suggested that the sulcal hyperattenuation was responsible for the sulcal hyperintensity, considering signal intensity and follow-up imaging. All patients with sulcal hyperintensity showed enhancement in the corresponding gyri on gadolinium-enhanced T1-weighted imaging. Hemorrhagic transformation developed in 5 of 8 patients with sulcal hyperintensity and in 1 of 4 patients without (P = 0.031).

Conclusions: In acute ischemic patients treated with intra-arterial thrombolysis, sulcal hyperintensity on FLAIR imaging may be caused by iodinated contrast medium, which should not be considered SAH. Sulcal hyperintensity is significantly associated with subsequent HT.

From the *Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; †Department of Radiology, Kangwon National University College of Medicine, Chunchon, Korea; ‡Department of Radiology, Research Institute of Radiologic Science, Yonsei University College of Medicine, Seoul, Korea; §Department of Radiology, Seoul National University College of Medicine, Seoul, Korea; ∥Department of Radiology, Gyeongsang National University College of Medicine, Jinju-Si, Korea; and ¶Department of Radiology, School of Medicine, Catholic University of Daegu, Daegu, Korea.

Received for publication September 5, 2004; accepted January 3, 2005.

Reprints: Soo Kim, Department of Radiology, Kangwon National University Hospital, 17-1 Hyoja 3-dong, Chunchon, Kangwon-do 200-947, Korea (e-mail:

© 2005 Lippincott Williams & Wilkins, Inc.