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Stroke and SAH mimics after coronary angioplasty

CASE REPORTS
175

Acute ischemic stroke mimicking subarachnoid hemorrhage
after coronary angioplasty
ANA PIRŠIĆ1, TOMISLAV ŠIPIĆ2, KREŠIMIR ŠTAMBUK2, HRVOJE BUDINČEVIĆ1, 3
1

Sveti Duh University Hospital, Department of Neurology, Stroke and Intensive Care Unit, Sveti Duh 64, 10000 Zagreb, Croatia
2
Magdalena Clinic for Cardiovascular Surgery and Cardiology, Department of Cardiology,
Ljudevita Gaja 2, 49217 Krapinske Toplice, Croatia
3
School of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia

Use of non-ionic contrast media (CM) in coronary arteriography has been reported to cause
transient cortical blindness, confusion, amnesia and very rare focal deficits. We report a 69-year old
patient with stable angina pectoris who underwent coronary angioplasty with stent placement due to
in-stent thrombosis of the right coronary artery and developed stroke symptoms with radiological
suspicion of subarachnoid hemorrhage. No vascular malformations were detected on CT cerebral
angiography. Dual antiplatelet treatment was continued. Complete neurological recovery was
observed within 48 hours post angiography. As observed with repeated CT scans, sulcal hyperdensities mostly faded after 24 hours and totally disappeared within 7 days when she was discharged
home. Our case shows transient neurological symptoms and rapid disappearing of sulcal
hyperdensities, suggesting temporary blood brain barrier disruption, consequential cerebral infarction
and contrast media extravasation as the main mechanisms which allowed us to treat the patient with
dual antiplatelet treatment.
Key words: neurotoxicity syndromes, contrast media, blood-brain barrier, cerebral infarction,
subarachnoid hemorrhage.

INTRODUCTION

Use of non-ionic contrast media (CM) in
coronary arteriography has been reported to cause
transient cortical blindness, confusion, amnesia and
very rare focal deficits [1, 2]. The proposed
mechanisms of neurotoxicity are disruption of the
blood-brain barrier (BBB) and a direct neurotoxic
effect by CM [3]. Abnormal contrast enhancement
on brain computed tomography (CT) scan after
diagnostic or interventional angiography is not rare
and has known to be induced by temporary BBB
disruption from CM [3]. The aim of this case report
is to show mimicking subarachnoid hemorrhage
(SAH) caused by contrast extravasation due to
dysfunction of BBB in acute ischemic stroke.
CASE REPORT

A 69-year old woman, with stable angina
pectoris, arterial hypertension, diabetes and stent
placement in right coronary artery (RCA) eight
years earlier, underwent transfemoral coronary angioplasty with recanalization and stent placement in
RCA due to subtotal in-stent restenosis. Additional
treatment included 10 000 IU heparin, aspirin 100 mg
ROM. J. INTERN. MED., 2017, 55, 3, 175–177

DOI: 10.1515/rjim-2017-0013

and clopidogrel 600 mg. A half an hour after the
procedure, she suffered chest pain with aphasia,
confusion and right hand paresis. She underwent
second interventional procedure with recanalization
and two stents placement due to confirmed acute
in-stent thrombosis, followed by eptifibatid bolus
and infusion. A non-ionic contrast iohexol was
used in both procedures, in an amount of 350 milliliters both times. Immediately after, she underwent
neurological examination which revealed recovery
of aphasia and persistence of right central facial
palsy, right mild hemiparesis and hemihypoesthesia
with facilitated tendon reflexes. Brain CT showed
acute cortical and subcortical frontoparietal cerebral
infarction with hyperdense (50-75 HU) content
filling the sulci of left hemisphere, which was
diagnosed as SAH (Fig. 1a). At this time the
patient was referred to our Stroke and Intensive
Care Unit. No vascular malformations were detected
on CT cerebral angiography. To consider other
causes of SAH, it is valuable to notice that prior to
this event, she was not treated with anticoagulation
therapy or steroids and she did not have any clinical
signs which would corroborate the diagnosis of
vasculitis or reversible cerebral vasoconstriction
syndrome. There were no signs of vasospasm
during transcranial doppler ultrasonography. Dual

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Ana Piršić et al.

antiplatelet treatment including aspirin and clopidogrel was continued. Complete neurological recovery
was observed within 48 hours after angiography.
As observed with repeated CT scans, cerebral

2

infarction was sequentially detected opposite to
sulcal hyperdensities that mostly faded after 24 hours
(Fig. 1b) and totally disappeared within 7 days
when she was discharged home (Fig. 1c).

Figure 1. Series of brain CT scans in patient with blood-brain barrier disruption, cortical and subcortical frontoparietal cerebral
infarction and hyperdense content filling the sulci of left hemisphere mimicking subarachnoid hemorrhage at 3h (a),
fading in 24 h (b) and totally disappeared in 7 days (c).
DISCUSSION

In-hospital cerebrovascular accident after
per-cutaneous coronary intervention (PCI) occurs
in about 0.30% of procedure [4]. Our case shows
transient neurological symptoms and rapid disappearing of sulcal hyperdensities, suggesting temporary
BBB disruption, consequential cerebral infarction
and CM extravasation as the main mechanisms that
allowed us to treat the patient with dual antiplatelet
therapy. The usage of dual antiplatelet therapy was
necessary in treatment of coronary disease and
ischemic stroke prevention. The coexistence of
SAH remains unlikely. Although the specificity of
CT for SAH is very high, physicians should be
aware of rare false positive findings [5]. CM extravasation could mimic radiologically SAH which is
likely to occur in cases in which more than one
revascularization is performed [6]. The density of
the lesion measured in Hounsfields units (HU)
could be a useful distinguishing characteristic,
which is confirmed in a recently published review
of 53 published cases of “contrast induced encephalopathy” noting that blood density is ranging
between 40 and 60 HU and contrast media usually
between 100 and 300 HU [7]. Magnetic resonance
imaging (MRI)-derived apparent diffusion coefficient
(ADC) was shown as a reliable imaging modality
that differentiates contrast extravasation from cerebral
ischemia [8]. Other authors have suggested dual

energy scanning (DECT) in distinguishing intracranial
hemorrhage from iodinated contrast extravasation
or staining [9]. In the absence of those techniques,
in stable patient with resolving symptoms, standard
of care could be repeated follow-up imaging [10],
usually showing that contrast staining generally
washes out within 24-48 hours, while hemorrhage
persists for days to weeks [9]. In our case, brain
MR was not performed because recent stent placement (hospital protocol does not allow MRI within
3 months after stent placement) [11] and clinical
improvement with contrast clearance on serial
brain CTs. The spinal puncture was not performed
based on our opinion that there would be a high
risk for spinal bleeding without a real benefit to the
patient. Physicians who treat the patients with
cerebrovascular complications after PCI, and who
do not have possibility of the proposed novel MRI
and CT techniques, could find our case report
helpful in making their clinical decisions. A careful
follow-up, especially in a stable patient with
resolving neurological deficit, would be reasonable
in order to postpone or completely avoid potentially
harmful additional CM administration and/or spinal
puncture with high risk of bleeding, in this group of
patients recently treated with multiple antithrombotic drugs.
Acknowledgements. None.
Conflict of Interest disclosure. The authors declare that there
are not conflicts of interest.

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Stroke and SAH mimics after coronary angioplasty

177

Folosirea substanţelor de contrast neionice pentru angiografie s-a asociat cu
cecitate tranzitorie, confuzie, amnezie şi foarte rar cu deficite de focar. Prezentăm
cazul unui pacient de 69 de ani cu angina stabilă care a suferit o angioplastie
coronariană cu amplasarea unui nou stent datorită dezvoltării unei tromboze la
nivelul stentului anterior şi care ulterior a dezvoltat semnele unui atac vascular
cerebral cu suspiciune radiologică de hemoragie subarahnoidiană. Nu au fost
detectate malformaţii ale arterelor cerebrale după realizarea angio-CT-ului.
Terapia dublă antiagregantă s-a continuat la acest pacient. Refacerea completă
neurologică s-a realizat la 48 de ore după realizarea angiografiei.Pacientului i-au
fost realizate analize CT înseriate şi s-au observant hiperdensităţi la nivelul
sulcului care s-au estompat la 24 de ore după atac şi care au dispărut complet la
7 zile, moment în care pacientul a fost externat. Cazul nostru prezintă simptome
tranzitorii neurologice şi o rapidă dispariţie a hiperdensităţilor sulcale, sugerând
o pierdere temporară a barierei hematoencefalice, cu dezvoltarea de infarct
cerebral şi extravazarea substanţei de contrast, permiţând abordarea pacientului
cu terapie dublă antiagregantă.
Correspondence to: HRVOJE BUDINČEVIĆ, MD, PhD,
Sveti Duh University Hospital. Department of Neurology,
Stroke and Intensive Care Unit. Sveti Duh 64, 10000 Zagreb, Croatia
E-mail: hbudincevic@gmail.com
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Received December 21, 2016