Delayed high dose contrast CT: identifying patients at risk of massive hemorrhagic infarction

A prospective clinical study was done on 20 patients referred for computed tomography within 28 hr of a cerebral ischemic event. The patients were scanned before, immediately after, and 3 hr after a high dose of intravenous contrast medium was administered to produce prolonged high blood iodine levels. In seven patients the delayed scan demonstrated a heretofore undescribed type of contrast enhancement which represents the early massive vasogenic edema seen in experimental animals before confluent hemorrhagic infarction. Four of the seven patients developed hemorrhagic infarction. None of the remaining 11 patients with cerebral infarctions and conventional postenhancement CT patterns showed hemorrhage on follow-up CT scans or at autopsy. Two patients with transient ischemic attacks had normal CT scans. It may now be possible to predict patients in whom there is high probability of hemorrhagic infarction before blood appears on CT. Treatment of these patients should probably be aimed at preventing the devastating effects of the vasogenic edema. We speculate that heparinization or bypass surgery to reestablish circulation may be contraindicated in this group.