Stroke: Haemorrhagic transformation - radiology video tutorial (CT, MRI)
Stroke: Haemorrhagic transformation - radiology video tutorial (CT, MRI)
“Stroke Series” video 6 of 7: Haemorrhagic transformation of ischaemic stroke. Discusses the important differences between petechial haemorhages and secondary haematomas. Presented by Neuroradiologist Dr Frank Gaillard.
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Content
4.98 -> hello again i'm frank gaillard from
7.229 -> radiopaedia.org in this our sixth
9.48 -> episode in our imaging of stroke series
11.459 -> we'll review hemorrhagic transformation
12.78 -> of ischemic stroke before we begin let's
16.11 -> have a look at three cases which of
18.09 -> these do you think represents
18.84 -> hemorrhagic transformation of a stroke
20.82 -> by the end of this episode you should be
23.009 -> able to make the distinction with
24.3 -> confidence in episode 4 of its series we
27.84 -> saw a natural progression of bland
29.46 -> ischemic stroke from the earliest signs
31.439 -> such as hyper dense artery all the way
33.45 -> through to an careful andalasia
34.91 -> hemorrhagic transformation is usually
37.14 -> seen in the first four days following
38.79 -> infarction but is rare in the first six
40.83 -> hours and magic transformation in one
43.17 -> form another is seen in over half of all
45.72 -> in facts although the reported rates
47.46 -> vary widely depending on definition and
49.59 -> modality two distinct processes fall
52.29 -> under this term these are petechial
54.57 -> hemorrhage and secondary hematoma as we
57.45 -> will see they not only appear different
59.25 -> but have different prognostic
60.45 -> implications as such it is important and
62.64 -> reports to ensure that when hemorrhagic
64.229 -> transformation is present one clearly
66.6 -> distinguishes between the two let's
69.06 -> first discuss petechial hemorrhages
70.88 -> petechial hemorrhages which pathologists
73.319 -> refer to as red softening macroscopic we
75.929 -> account for the vast majority of cases
77.46 -> with hemorrhagic transformation and
79.17 -> result in increased attenuation of the
80.939 -> affected brain in this case a CT
83.789 -> obtained acutely does not convincingly
85.59 -> demonstrate change but a follow-up study
87.78 -> two weeks later demonstrates increased
89.759 -> attenuation of the cortex this
91.679 -> appearance and timing could represent
93.299 -> fogging phenomenon we discussed in
95.429 -> episode 5 which typically occurs two to
97.709 -> three weeks after infarction if however
100.35 -> we review an MRI obtain one day after
102.569 -> onset of symptoms after TPA was
105.27 -> administered we could see a large in fog
107.13 -> and Jireh form susceptibility induced
109.289 -> signal dropout consistent with petechial
111.299 -> hemorrhaging transformation which
113.039 -> typically occurs within a day of
114.479 -> thrombolysis in this second case a large
117.42 -> right middle cerebral artery in fact is
119.729 -> again not clearly visible on the initial
121.59 -> scan or there minor blurring of the gray
123.45 -> white matter interfaces present the next
125.88 -> day on MRI the in fact is easily seen on
128.22 -> DWI and the echo plane our imaging
130.83 -> signal lost signal into form nucleus
132.84 -> again consistent with particular
134.7 -> hemorrhagic transformation two days
136.739 -> later still this region demonstrate
138.7 -> increased attenuation on CT petechial
141.73 -> hemorrhages result from small amounts of
143.86 -> blood seeping out of vessels damaged by
146.56 -> ischemia into nearby tissues they do not
149.38 -> have mass effects and generally do not
151.03 -> impact on prognosis or treatment now on
154.9 -> to the far more sinister secondary
156.76 -> hematoma as we have seen the vast
159.22 -> majority of ischemic strokes without
161.11 -> interventions undergo progression which
164.11 -> does not include a secondary hematoma
166.209 -> formation a small minority say 5% will
169.3 -> however spontaneously hemorrhage and
171.28 -> only a subset of these are symptomatic
173.14 -> this is easy to understand when you look
175.54 -> at this case the hematomas are
177.91 -> relatively small and embedded in brain
180.22 -> that is already in fact and thus no
182.41 -> symptoms arise from these hematomas the
185.08 -> cause of hemorrhagic transformation is
186.79 -> thought to be due in the majority of
188.23 -> cases to early reperfusion of in fact in
190.54 -> tissue the damaged vessels are unable to
192.73 -> withstand arterial pressures and rupture
195.299 -> collateral flow is also implicated in
197.62 -> some patients as secondary hematoma can
199.75 -> be seen in patients without
200.95 -> recanalization the rate is significantly
203.38 -> higher when reperfusion therapy is
205.66 -> employed such as intravenous or interact
208.63 -> irreal thrombolysis or clock retrieval
210.549 -> the rate of symptomatic secondary
212.62 -> hematoma formation in these patients is
214.63 -> variably reported when it's up to 6% in
217.15 -> those treated with IV TPA the importance
220.359 -> of hemorrhagic transformation with
222.269 -> hematoma formation is that it is
224.709 -> associated with a much poorer outcome
226.6 -> this is particularly troublesome in the
228.67 -> context of active reperfusion therapy as
230.95 -> in the process of trying to improve
232.69 -> outcome one can inadvertently make the
234.88 -> patient much worse as a result a great
236.98 -> deal of research into acute stroke
238.81 -> management has been focused on time to
240.76 -> accurately select the subgroup of
242.44 -> patients who will get the most benefit
244.359 -> from therapy and are at the lowest risk
246.79 -> of hemorrhagic transformation we will
249.34 -> cover this in some detail in our final
251.709 -> episode in this series secondary
254.44 -> hematomas tend to occur spontaneously
255.85 -> within the first four days after
257.859 -> infarction but are rare in the first six
260.889 -> hours and typically occur within a day
263.41 -> after reperfusion therapy in most cases
265.99 -> the diagnosis is obvious the fact that
267.909 -> the patient had a previous ischemic
269.65 -> stroke is either reached on the request
271.479 -> card or is
272.2 -> and from the CT scan as is the case here
274.84 -> where a day earlier the patient had a
277.27 -> hyper dense MCA sign a distal m1
279.7 -> occlusion and a perfusion defect some
282.64 -> difficulty can occur when the first
284.32 -> studies obtained some time after onset
286.45 -> of symptoms at which time hemorrhage is
288.76 -> already present if this was the first CT
291.19 -> you had available to you one needs to
293.02 -> decide whether this represents lobar
294.85 -> hemorrhage or hemorrhagic transformation
296.64 -> although this is a straightforward
298.39 -> example with little straits many of the
300.25 -> features typical of secondary hematomas
302.38 -> there is nothing particular about the
304.03 -> hematomas themselves although they
305.71 -> usually multifocal the key to the
307.87 -> diagnosis is a surrounding brain in most
310.27 -> cases one can see evidence of an
311.95 -> established but non hemorrhagic
313.27 -> component which conforms to an expected
315.67 -> vascular territory the cortex is
317.77 -> involved as well as the white matter
319.57 -> indicating cytotoxic rather than razor
321.73 -> genic edema so looking at our three
324.28 -> cases you can see that case a has these
326.77 -> features there is a region of cytotoxic
329.17 -> edema involving most of the mca
330.94 -> territory but sparing the pca territory
333.28 -> hemorrhage accounts for only part of the
335.41 -> abnormality case B has a large hematoma
338.17 -> with only a small amount of vasogenic
340.15 -> edema surrounding it it also seems to
342.67 -> involve both the MCA and a CA territory
345.4 -> but no abnormality of the rest of the
347.2 -> MCA territory is visible this represents
349.96 -> a primary lobar hemorrhage case C is a
352.99 -> small circumscribed mass with only some
355.66 -> vasogenic edema seen in the adjacent
357.55 -> white matter the adjacent cortex is
359.74 -> normal in appearance this represents a
361.6 -> hemorrhagic metastasis you can of course
364.72 -> find out much more about hemorrhagic
366.46 -> transformation on radiopaedia.org
369.15 -> [Music]
377.34 -> you
Source: https://www.youtube.com/watch?v=7q1pSz6jCWM