Skip to main content
SpringerLink
Log in

Dual-energy CT for differentiating acute intracranial hemorrhage from contrast staining or calcification: a meta-analysis

  • Diagnostic Neuroradiology
  • Published:
Neuroradiology Aims and scope Submit manuscript

Abstract

Purpose

This study aimed to comprehensively evaluate the diagnostic performance of dual-energy CT (DECT) for differentiating acute intracranial hemorrhage (ICH) from contrast staining or small calcifications via a systematic review and meta-analysis.

Methods

The PubMed–MEDLINE, EMBASE, and Cochrane Library databases were searched up to November 10, 2019. Original studies (prospective or retrospective cohort studies) with the primary aim of detecting ICH using DECT were selected. The diagnostic performance of DECT was assessed using bivariate and hierarchical summary receiver operating characteristic models. Quality assessment was performed according to the Quality Assessment of Diagnostic Accuracy Studies-2, while between-study heterogeneity was assessed using Higgins’ inconsistency index (I2). To explore heterogeneity, subgroup meta-regression analyses were performed. Deeks’ funnel plot asymmetry test was used for assessing publication bias.

Results

Nine studies comprising 402 patients with 453 lesions were included for data synthesis. The overall pooled sensitivity and specificity of DECT for ICH detection were 96% (95% CI, 77–99%) and 98% (95 CI, 93%–100%), respectively. Substantial and moderate between-study heterogeneities were observed for sensitivity (I2 = 90.3%) and specificity (I2 = 57.9%), respectively. In meta-regression analysis, type of cohort affected heterogeneity—studies including only stroke patients showed lower sensitivity (43.5% vs. 94.2%) but higher specificity (98.7% vs. 92.6%) than those with mixed etiologies (P < 0.001). Deeks’ funnel plot asymmetry test revealed publication bias (P = 0.020).

Conclusion

DECT demonstrated excellent diagnostic performance in terms of differentiating acute ICH from contrast staining and small calcifications. However, publication bias suggests the possibility of overestimated diagnostic performance, warranting large-scale, prospective cohort studies.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

Availability of data and material (data transparency)

Not applicable.

References

  1. Parizel P, Makkat S, Van Miert E, Van Goethem J, van den Hauwe L, De Schepper A (2001) Intracranial hemorrhage: principles of CT and MRI interpretation. Eur Radiol 11(9):1770–1783. https://doi.org/10.1007/s003300000800

    Article  CAS  PubMed  Google Scholar 

  2. Payabvash S, Qureshi MH, Khan SM, Khan M, Majidi S, Pawar S, Qureshi AI (2014) Differentiating intraparenchymal hemorrhage from contrast extravasation on post-procedural noncontrast CT scan in acute ischemic stroke patients undergoing endovascular treatment. Neuroradiology 56(9):737–744. https://doi.org/10.1007/s00234-014-1381-8

    Article  PubMed  Google Scholar 

  3. Renú A, Amaro S, Laredo C, Román LS, Llull L, Lopez A, Urra X, Blasco J, Oleaga L, Chamorro Á (2015) Relevance of blood–brain barrier disruption after endovascular treatment of ischemic stroke: dual-energy computed tomographic study. Stroke 46(3):673–679

    Article  Google Scholar 

  4. Fiorelli M, Bastianello S, von Kummer RD, Del Zoppo GJ, Larrue V, Lesaffre E, Ringleb AP, Lorenzano S, Manelfe C, Bozzao L (1999) Hemorrhagic transformation within 36 hours of a cerebral infarct: relationships with early clinical deterioration and 3-month outcome in the European Cooperative Acute Stroke Study I (ECASS I) cohort. Stroke 30(11):2280–2284

    Article  CAS  Google Scholar 

  5. Khatri P, Wechsler LR, Broderick JP (2007) Intracranial hemorrhage associated with revascularization therapies. Stroke 38(2):431–440

    Article  Google Scholar 

  6. Nute JL, Le Roux L, Chandler AG, Baladandayuthapani V, Schellingerhout D, Cody DD (2015) Differentiation of low-attenuation intracranial hemorrhage and calcification using dual-energy computed tomography in a phantom system. Investig Radiol 50(1):9–16

    Article  CAS  Google Scholar 

  7. Makariou E, Patsalides AD (2009) Intracranial calcifications. Appl Radiol 38(11):48

    Google Scholar 

  8. Chen W, Zhu W, Kovanlikaya I, Kovanlikaya A, Liu T, Wang S, Salustri C, Wang Y (2014) Intracranial calcifications and hemorrhages: characterization with quantitative susceptibility mapping. Radiology 270(2):496–505

    Article  Google Scholar 

  9. Morhard D, Ertl L, Gerdsmeier-Petz W, Ertl-Wagner B, Schulte-Altedorneburg G (2013) Dual-energy CT immediately after endovascular stroke intervention: prognostic implications. Cardiovasc Intervent Radiol 37:1–8. https://doi.org/10.1007/s00270-013-0804-y

    Article  Google Scholar 

  10. Tijssen MP, Hofman PA, Stadler AA, van Zwam W, de Graaf R, van Oostenbrugge RJ, Klotz E, Wildberger JE, Postma AA (2014) The role of dual energy CT in differentiating between brain haemorrhage and contrast medium after mechanical revascularisation in acute ischaemic stroke. Eur Radiol 24(4):834–840. https://doi.org/10.1007/s00330-013-3073-x

    Article  CAS  PubMed  Google Scholar 

  11. Bonatti M, Lombardo F, Zamboni GA, Vittadello F, Curro Dossi R, Bonetti B, Pozzi Mucelli R, Bonatti G (2018) Iodine extravasation quantification on dual-energy CT of the brain performed after mechanical thrombectomy for acute ischemic stroke can predict hemorrhagic complications. AJNR Am J Neuroradiol 39(3):441–447. https://doi.org/10.3174/ajnr.A5513

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Gupta R, Phan CM, Leidecker C, Brady TJ, Hirsch JA, Nogueira RG, Yoo AJ (2010) Evaluation of dual-energy CT for differentiating intracerebral hemorrhage from iodinated contrast material staining. Radiology 257(1):205–211. https://doi.org/10.1148/radiol.10091806

    Article  PubMed  Google Scholar 

  13. Phan CM, Yoo AJ, Hirsch JA, Nogueira RG, Gupta R (2012) Differentiation of hemorrhage from iodinated contrast in different intracranial compartments using dual-energy head CT. AJNR Am J Neuroradiol 33(6):1088–1094. https://doi.org/10.3174/ajnr.A2909

    Article  CAS  PubMed  Google Scholar 

  14. Watanabe Y, Tsukabe A, Kunitomi Y, Nishizawa M, Arisawa A, Tanaka H, Yoshiya K, Shimazu T, Tomiyama N (2014) Dual-energy CT for detection of contrast enhancement or leakage within high-density haematomas in patients with intracranial haemorrhage. Neuroradiology 56(4):291–295. https://doi.org/10.1007/s00234-014-1333-3

    Article  PubMed  Google Scholar 

  15. Bodanapally UK, Dreizin D, Issa G, Archer-Arroyo KL, Sudini K, Fleiter TR (2017) Dual-energy CT in enhancing subdural effusions that masquerade as subdural hematomas: diagnosis with virtual high-monochromatic (190-keV) images. AJNR Am J Neuroradiol 38(10):1946–1952. https://doi.org/10.3174/ajnr.A5318

    Article  CAS  PubMed  Google Scholar 

  16. Wiggins WF, Potter CA, Sodickson AD (2019) Dual-energy CT to differentiate small foci of intracranial hemorrhage from calcium. Radiology 190792. https://doi.org/10.1148/radiol.2019190792

  17. Hu R, Besheli LD, Young J, Wu M, Pomerantz S, Lev MH, Gupta R (2016) Dual-energy head CT enables accurate distinction of intraparenchymal hemorrhage from calcification in emergency department patients. Radiology 280(1):177–183. https://doi.org/10.1148/radiol.2015150877

    Article  PubMed  Google Scholar 

  18. Johnson TR (2012) Dual-energy CT: general principles. Am J Roentgenol 199(5_supplement):S3–S8

    Article  Google Scholar 

  19. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Ann Intern Med 151(4):W65–W94. https://doi.org/10.7326/0003-4819-151-4-200908180-00136

    Article  PubMed  Google Scholar 

  20. Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeflang MM, Sterne JA, Bossuyt PM (2011) QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 155(8):529–536

    Article  Google Scholar 

  21. Higgins J (2011) Cochrane handbook for systematic reviews of interventions. Version 5.1. 0 [updated March 2011]. The Cochrane Collaboration. www.cochrane-handbook.org

  22. Devillé WL, Buntinx F, Bouter LM, Montori VM, De Vet HC, Van der Windt DA, Bezemer PD (2002) Conducting systematic reviews of diagnostic studies: didactic guidelines. BMC Med Res Methodol 2(1):9

    Article  Google Scholar 

  23. Deeks JJ, Macaskill P, Irwig L (2005) The performance of tests of publication bias and other sample size effects in systematic reviews of diagnostic test accuracy was assessed. J Clin Epidemiol 58(9):882–893

    Article  Google Scholar 

  24. Ebashi R, Ogata A, Nishihara M, Inoue K, Yoshioka F, Takase Y, Masuoka J, Yakushiji Y, Irie H, Hara H, Abe T (2019) Significance of simulated conventional images on dual energy CT after endovascular treatment for ischemic stroke. J NeuroInterv Surg 11(9):898–902. https://doi.org/10.1136/neurintsurg-2018-014486

    Article  PubMed  Google Scholar 

  25. Paciaroni M, Agnelli G, Corea F, Ageno W, Alberti A, Lanari A, Caso V, Micheli S, Bertolani L, Venti M (2008) Early hemorrhagic transformation of brain infarction: rate, predictive factors, and influence on clinical outcome: results of a prospective multicenter study. Stroke 39(8):2249–2256

    Article  Google Scholar 

  26. Gn S, Cangür H, Albers T, Burgemeister A, Meyer-Wiethe K (2009) Sonographic evaluation of hemorrhagic transformation and arterial recanalization in acute hemispheric ischemic stroke. Stroke 40(1):119–123

    Article  Google Scholar 

  27. Hamann GF, del Zoppo GJ, von Kummer R (1999) Hemorrhagic transformation of cerebral infarction–possible mechanisms. Thromb Haemost 82(S 01):92–94

    Article  Google Scholar 

Download references

Funding

No funding was received for this study.

Author information

Authors and Affiliations

  1. Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, South Korea

    Yangsean Choi, Na-Young Shin, Jinhee Jang, Kook-Jin Ahn & Bum-soo Kim

Authors
  1. Yangsean Choi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Na-Young Shin
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jinhee Jang
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kook-Jin Ahn
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Bum-soo Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Na-Young Shin.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethics approval

This is a retrospective literature review study. Our institutional review board (IRB) has confirmed that no ethical approval is required (IRB No. KC19ZISI0865).

Consent to participate

Written informed consent was not required for this study because it is a meta-analysis based on studies that have already been published.

Consent for publication

Written informed consent was not required for this study because it is a meta-analysis based on studies that have already been published.

Code availability (software application or custom code)

Not applicable.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Choi, Y., Shin, NY., Jang, J. et al. Dual-energy CT for differentiating acute intracranial hemorrhage from contrast staining or calcification: a meta-analysis. Neuroradiology 62, 1617–1626 (2020). https://doi.org/10.1007/s00234-020-02486-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00234-020-02486-w

Keywords

Search

Navigation