Contrast extravasation mimicking intracerebral and intraventricular hemorrhage after intravenous thrombolytic treatment of ischemic stroke: a case report.

BACKGROUND: Although contrast extravasation on follow-up head computed tomography (CT) is frequently visualized after endovascular treatment, this phenomenon is rare after intravenous thrombolytic treatment in patients with acute ischemic stroke (AIS). Here, we report a case of contrast extravasation mimicking intracerebral hemorrhage (ICH) with intraventricular extension after intravenous thrombolytic treatment and computed tomography angiography (CTA). CASE PRESENTATION: A 52-year-old man presented with right-sided hemiparesis and hypoesthesia. Initial non-contrast head CT was negative for intracranial hemorrhage and acute ischemic changes. He received intravenous treatment with tenecteplase 3.8 h after the onset of stroke. CTA of the head and neck was performed at 4.3 h after stroke onset. It showed no stenosis or occlusion of the carotid and major intracranial arteries. At about 1.5 h after CTA, the right-sided hemiparesis deteriorated, accompanied by drowsiness, aphasia, and urinary incontinence. Immediate head CT showed hyperdense lesions with mild space-occupying effect in the left basal ganglia and both lateral ventricles. The hyperdense lesions were reduced in size on follow-up CT after 5 h. Two days later, CT showed that the hyperdense lesions in the lateral ventricles almost completely disappeared and only a small amount remained in the infarcted area. CONCLUSIONS: Contrast extravasation into the brain tissue and lateral ventricles, mimicking ICH with intraventricular extension, could occur after intravenous thrombolytic treatment and CTA in a patient with AIS, which might lead to misdiagnosis and wrong treatment of the patient. The rapid resolution of intracranial hyperdense lesions is key to differentiate contrast extravasation from ICH on serial non-enhanced CT.

Extravasation and infiltration: under-recognised complications of intravenous therapy.

Occasionally, the administration of intravenous (IV) therapies can go wrong. Infiltration or extravasation is a complication when a drug or IV therapy leaks into the tissues surrounding the vascular access device. Extravasation can cause serious and often life-changing injuries. Extravasation is often associated with systemic anti-cancer therapy but non-chemotherapy drugs have been reported as having a greater risk of serious complications. This study outlines the first UK Infusion unit evaluation of the ivWatch infusion monitoring device which was undertaken from August 2023 to January 2024. Out of 2254 infusions monitored with ivWatch, the device prevented 122 cases of infiltration and extravasation from causing any harm to the patient, corresponding to a 5.4% 'check IV' notification rate.

Hypotension in the Emergency Department and Contrast Extravasation on Computerized Tomography Predict Blood Transfusion in Low-Energy Pelvic Fractures.

INTRODUCTION: Although low-energy pelvic fractures seldom present with significant hemorrhage, early recognition of at-risk patients is essential. We aimed to identify predictors of transfusion requirements in this cohort. METHODS: A 7-y retrospective chart review was performed. Low-energy mechanism was defined as falls of ≤5 feet. Fracture pattern was classified using the Orthopedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen system as A, B, or C. Primary outcome was transfusion of ≥2 units of packed red blood cells in the first 48 h. Univariable analysis and logistic regression analysis were performed. A P value ≤0.05 was considered significant. RESULTS: Five hundred forty six patients were included with median (interquartile range) age of 86 (79-91) and median (interquartile range) Injury Severity Score of 5 (4-8). Five hundred forty one (99%) had type A fractures. Twenty six (5%) had the primary outcome and 17 (3%) died. Logistic regression found that systolic blood pressure <100 mmHg at any time in the Emergency Department, Injury Severity Score, and pelvic angiography were predictors of the primary outcome. Seventeen percent of those who had the primary outcome died compared with 2% who did not (P = 0.0004). Three hundred sixty four (67%) received intravenous contrast for computerized tomography scans and of these, 44 (12%) had contrast extravasation (CE). CE was associated with the primary outcome but not mortality. CONCLUSIONS: Hypotension at any time in the Emergency Department and CE on computerized tomography predicted transfusion of ≥2 units packed red blood cells in the first 48 h in patients with low-energy pelvic fractures.

GEDEFO-SEFH management of antineoplastic extravasations survey results.

INTRODUCTION: Extravasation is a potentially severe complication of intravenous administration of antineoplastic drugs. The limited data makes it difficult to develop an optimal management scheme. The objective of this study is to describe the clinical practice in the extravasation management of antineoplastic agents in Spanish centers. METHODS: An online survey was distributed to oncology pharmacists using the email distribution list of the Spanish Society of Hospital Pharmacists. Respondents were surveyed on the standard operational protocol (SOP) of extravasation, tissue damage risk classification, and specific measures of extravasation management. RESULTS: A total of 68 surveys were completed. A specific extravasation SOP was available in 82.4% centers. The pharmacist participates in the authorship (100%) and actively collaborates in extravasation management (76.5%). A tissue damage risk classification based on the three categories was mostly adopted (48.2%) and 73.2% applied specific criteria based on concentration and/or extravasated volume. Extravasation management was mainly performed with the application of physical measures and/or antidotes (91.2%). High variability in the choices of pharmacological and/or physical measures recommended is outstanding. CONCLUSION: The results of this study highlight the involvement of Spanish pharmacists in extravasation management, the application of physical measures and/or pharmacological measures as the method of choice in extravasation management, as well as the existing discrepancies in tissue damage risk classification and management recommendations.

Association of Contrast Extravasation Grade With Massive Transfusion in Pediatric Blunt Liver and Spleen Injuries: A Multicenter Retrospective Cohort Study.

BACKGROUND: This study aimed to assess whether the grade of contrast extravasation (CE) on CT scans was associated with massive transfusion (MT) requirements in pediatric blunt liver and/or spleen injuries (BLSI). METHODS: This multicenter retrospective cohort study included pediatric patients (≤16 years old) who sustained BLSI between 2008 and 2019. MT was defined as transfusion of all blood products ≥40 mL/kg within the first 24 h of admission. Associations between CE and MT requirements were assessed using multivariate logistic regression analysis with cluster-adjusted robust standard errors to calculate the adjusted odds ratio (AOR). RESULTS: A total of 1407 children (median age: 9 years) from 83 institutions were included in the analysis. Overall, 199 patients (14 %) received MT. CT on admission revealed that 54 patients (3.8 %) had CE within the subcapsular hematoma, 100 patients (7.1 %) had intraparenchymal CE, and 86 patients (6.1 %) had CE into the peritoneal cavity among the overall cohort. Multivariate analysis, adjusted for age, sex, age-adjusted shock index, injury severity, and laboratory and imaging factors, showed that intraparenchymal CE and CE into the peritoneal cavity were significantly associated with the need for MT (AOR: 2.50; 95 % CI, 1.50-4.16 and AOR: 4.98; 95 % CI, 2.75-9.02, respectively both p < 0.001). The latter significant association persisted in the subgroup of patients with spleen and liver injuries. CONCLUSION: Active CE into the free peritoneal cavity on admission CT was independently associated with a greater probability of receiving MT in pediatric BLSI. The CE grade may help clinicians plan blood transfusion strategies. LEVEL OF EVIDENCE: Level 4; Therapeutic/Care management.

CT contrast extravasation in children: a single-center experience and systematic review.

BACKGROUND: Extravasation of iodinated contrast material during computed tomography (CT) is a rare complication. A few patients may develop severe complications such as compartment syndrome. OBJECTIVE: The purpose of this study was to retrospectively assess the prevalence, severity, management, and outcome of contrast extravasations in our institution and to perform a comparison to what has been reported in the existing literature. MATERIALS AND METHODS: This is a research ethics board (REB)-approved retrospective study comprising 11 patients who had intravenous contrast-enhanced CT between 2019 and 2022 in a tertiary pediatric center, and experienced extravasation of iodinated contrast as a complication. Age, weight, sex, co-morbidities, angiocatheter size, venous access location, total contrast volume, flow rate, patient's symptoms, severity of injury, and management were collected. For the systematic review, PRISMA guidelines were followed. RESULTS: Only 11 (0.3%) (0.17-0.54 (95%CI)) contrast extravasations occurred in a total of 3638 CTs performed with intravenous contrast during the same period in children. The median age (IQR) was 12.5 (10.0, 15.0) years. In our cohort, 1/11 patients developed compartment syndrome and required fasciotomy. The systematic review assessed 12 articles representing a population of 110 children with extravasations. Pooled prevalence from articles stratified by age was 0.32% (0.06-0.58% (95%CI)). Only three children experienced moderate to severe complications. CONCLUSIONS: We confirm that severe complications of contrast extravasation are rare and can occur at any age. No strong associations were seen with the need for surgical consultation (including age, sex, weight, flow rate, injection site, catheter size, and type of contrast).

Crucial factors for implementing treatment strategies in intractable atonic postpartum haemorrhage: early phase contrast medium extravasation on dynamic CT.

AIM: To identify the relationship between contrast medium extravasation (CME) on dynamic contrast-enhanced computed tomography (DCT) and clinical information in intractable atonic postpartum haemorrhage (PPH) and its relevance to treatment with uterine artery embolisation (UAE). MATERIALS AND METHODS: Of 90 patients who underwent DCT to diagnose PPH, 60 diagnosed with intractable atonic PPH were investigated retrospectively. Maternal background and clinical indicators were analysed to compare the positive and negative factors of early phase CME. Regression analysis was used to investigate the factors associated with CME. The sensitivity, specificity, and positive and negative predictive values of early phase CME for predicting UAE were calculated. Clinical outcomes were compared between the two groups according to the timing of the decision to undergo UAE. RESULTS: Of the 60 patients with intractable atonic PPH, 21 underwent UAE, 20 of whom had early phase CME on DCT. Pre-DCT clinical parameters and clinical indices were not significantly different in presence of early phase CME. Early phase CME was associated with UAE performance, with a sensitivity of 95%, specificity of 87%, positive predictive value of 80%, and negative predictive value of 97%. In cases where UAE was performed after conservative management, there was a significant increase in blood loss and transfusion volume. CONCLUSION: Early phase CME is not indicated by background factors or clinical findings. UAE is not required when CME cannot be detected in the uterine cavity. If early phase CME is present, UAE should be considered immediately.

Extravasation of Non-Cytotoxic Drugs in Older People.

Objective To describe the risk factors of extravasation, its impact on the pharmacokinetics of non-cytotoxic drugs, and management of extravasation in older individuals. Extravasation occurs when vesicants leak from blood vessels into surrounding tissue causing severe injury such as tissue necrosis while infiltration is caused by leakage of an irritant that causes injury but does not lead to tissue necrosis. Extravasation occurs in approximately 0.01% to 6% of patients, particularly with cytotoxic agents. However, there is limited documentation about extravasation of non-cytotoxic agents, particularly in older people. Data Sources A literature search of Pubmed and Medline was performed using the following search items: "extravasation," "infiltration," "elderly," and "non-cytotoxic drugs," as well as a combination of these terms. Conclusion It is important to recognize, identify, and manage extravasation early since it can have deleterious consequences for older people. It is more important to prevent extravasation than manage it using standardized evidence-based protocols, and this can be implemented in the nursing facility and acute care setting.

Contrast media extravasation injury: a prospective observational cohort study.

OBJECTIVE: To identify the risk factors for moderate and severe contrast media extravasation and provide effective guidance to reduce the degree of extravasation injuries. METHODS: We observed 224 adult patients who underwent contrast media extravasation at Xiangya Hospital of Central South University, Hunan Provincial Maternal and Child Healthcare Hospital, and Xiangya Changde Hospital, Hunan Province between January 1, 2018 and December 31, 2022. Risk factors for moderate extravasation injuries were evaluated using univariate and multivariate logistic regression. RESULTS: Among 224 patients, 0 (0%) had severe, 18 (8.0%) had moderate, and 206 (92.0%) had mild contrast media extravasation injury. Multivariate logistic regression analysis revealed malignant tumors (odds ratio [OR] = 6.992, 95% confidence interval [CI]: 1.674-29.208), Iohexol (OR = 9.343, 95% CI 1.280-68.214), large-volume (> 50 mL) extravasation (OR = 5.773, 95% CI 1.350‒24.695), and injection site (back of the hand) (OR = 13.491, 95% CI 3.056-59.560) as independent risk factors for moderate injury. CONCLUSION: Risk factors for moderate contrast media extravasation injury are malignant tumors, iohexol, large-volume (> 50 mL) extravasation, and back-of-the-hand injection. Analysis of these risk factors can help reduce the degree of injury after extravasation. CLINICAL RELEVANCE STATEMENT: High-risk patients with extravasation support should choose the appropriate contrast media type, avoiding back-of-the-hand injections. We recommend that patients with cancer be implanted with a high-pressure resistant central venous catheter and receive effective measures to timely detect and reduce extravasation.

Pelvic ring fractures with concomitant large hematomas: diagnostic investigation with arteriography and eventual embolization in 157 trauma patients, with or without contrast extravasation at emergency CT.

PURPOSE: This study aims to evaluate the diagnostic value of pelvic arteriography in patients with pelvic ring fractures and associated large hematomas, in both cases of positive or negative findings of contrast agent extravasation at emergency CT; in those patients with positive DSA subsequently treated with embolization, correlations with clinical-radiological parameters were investigated. MATERIALS AND METHODS: In this single-center retrospective study, patients with acute blunt pelvic trauma showing at CT pelvic ring fractures with associated large (> 3 cm) hematoma, with or without signs of arterial bleeding, were investigated with DSA. Technical success was considered radiographic bleeding control with disappearance of angiographic bleeding; clinical success was defined as clinical bleeding control hemodynamically stable, before applying other surgical maneuvers. Pelvic ring fractures were evaluated according to Tile classification system. RESULTS: One hundred and fifty-seven patients, mean age 54years, were analyzed. 70.7% had polytrauma; 14.6% patients assumed antiplatelets and/or anticoagulation therapy. False-negative and false-positive rates at CT were 29.6% and 27.1%, respectively. Polytrauma and B3/C1 Tile pattern fractures were significantly associated with bleeding signs at DSA. Seventy-two patients required embolization: 52.8% showed direct signs of DSA bleeding; among these, technical and clinical successes were 88.8% and 81.9%, respectively. CONCLUSIONS: In this study, patients with pelvic ring fractures and concomitant hematomas > 3 cm, with or without contrast extravasation at CT, have been examined in depth with DSA focusing on both direct and indirect angiographic signs of bleeding, finding polytrauma and Tile fracture patterns B3/C1 predictive factors for arterial hemorrhage detection at DSA despite negative CT findings.

Profiles and Outcomes of Skin Injuries Caused by Injectable Drug Extravasation: An Analysis of the Japanese Adverse Drug Event Report Database.

Extravasation occurs when injectable drugs leak out of the blood vessels, damaging the surrounding tissues and causing a variety of skin injuries. This study aimed to comprehensively analyze extravasation risk, skin injury profiles, and outcomes for suspect drugs from the Japanese Adverse Drug Event Report (JADER) database. Adverse events were defined according to the Medical Dictionary for Regulatory Activities/Japanese version; the term extravasation (Standardized MedDRA Query Code: 20000136) was used in this analysis. The names of adverse events were entered as unified preferred terms and redefined to evaluate skin injury profiles. In addition, skin injury outcomes were divided into 2 broad categories: "improvement" and "no improvement." Reporting odds ratios were used to detect signals for adverse events. A total of 656 cases of extravasation-related adverse events were reported between April 2004 and January 2022. Signals for extravasation-related adverse events were detected from 11 drugs. Then, their respective skin injury profiles and outcomes were determined. These results suggest a relationship between adverse events associated with extravasation and 11 drugs and identify the characteristics of each skin injury and their outcomes. These findings will contribute to improving the quality of infusion management in clinical practice.

Percepção do enfermeiro sobre os cuidados relacionados ao extravasamento de drogas antineoplásicas / Percepción de profesionales de enfermería sobre los cuidados relacionados con la extravasación de medicamentos antineoplásicos / Perception of the nursing professional about the care related to extravasation of antineoplastic drugs

Introdução: O uso de quimioterapias antineoplásicas atuando a nível celular com objetivo de tratar as neoplasias malignas, pode levar ao surgimento da toxicidade dermatológica, ocasionada pelo extravasamento, que consiste em um dano tecidual decorrente da infiltração, por via endovenosa, dos quimioterápicos aos tecidos circunvizinhos do local puncionado, necessitando de uma atuação profissional rápida e efetiva para evitar desfechos desfavoráveis para o paciente. Objetivo: Compreender a percepção do enfermeiro sobre os cuidados relacionados ao extravasamento de drogas antineoplásicas. Método: Trata-se de um estudo de campo, descritivo-exploratório com abordagem qualitativa, realizado com quinze enfermeiros que atuam no ambulatório e enfermarias da oncologia adulto de uma instituição hospitalar filantrópica localizada em Recife/Pernambuco, Brasil. Os dados foram coletados entre janeiro e dezembro de 2020 através de entrevista e passaram por análise de conteúdo temática-categorial. Resultados: Emergiram duas categorias. Cuidados preventivos: da identificação dos fatores de riscos à educação do paciente e equipe de saúde; Cuidados diretos: da identificação da ocorrência ao gerenciamento institucional do evento. Conclusão: Compreendeu-se que a percepção do enfermeiro destaca a importância do planejamento da assistência, incluindo a intervenção imediata, o registro do evento e o acompanhamento do paciente após o extravasamento, como forma de realizar um cuidado especializado e com maior segurança.

Introducción: El uso de quimioterapias antineoplásicas que actúan a nivel celular con el objetivo de tratar neoplasias malignas puede conducir a la aparición de toxicidad dermatológica. Esta es causada por extravasación, que consiste en daño tisular producto de la infiltración, por vía endovenosa, de los agentes quimioterápicos a los tejidos circundantes del sitio de punción. Lo anterior, requiere una actuación profesional rápida y eficaz para evitar resultados desfavorables para la persona. Objetivo: Comprender la percepción de profesionales de enfermería sobre el cuidado relacionado con la extravasación de fármacos antineoplásicos. Método: Se trata de un estudio de campo descriptivo-exploratorio con abordaje cualitativo, realizado con quince personas enfermeras que actúan en las salas de oncología de población adulta y ambulatoria de un hospital filantrópico ubicado en Recife/Pernambuco, Brasil. Los datos fueron recolectados entre enero y diciembre de 2020, a través de entrevistas y fueron sometidos a análisis de contenido por categorías temáticas. Resultados: Emergieron dos categorías: atención preventiva (desde la identificación de factores de riesgo hasta la educación de la persona y del equipo de salud) y atención directa (desde la identificación de la ocurrencia hasta la gestión institucional del evento). Conclusión: Se entendió que la percepción de la persona profesional de enfermería destaca la importancia de la planificación del cuidado, incluyendo la intervención inmediata, el registro de eventos y el seguimiento después de la extravasación, como forma de realizar cuidados especializados y con mayor seguridad.

Introduction: The use of antineoplastic chemotherapies acting at the cellular level with the aim of treating malignant neoplasms can lead to the emergence of dermatological toxicity caused by extravasation. This toxicity consists of tissue damage resulting from the infiltration, by intravenous route, of the chemotherapeutic agents to the surrounding tissues, requiring quick and effective professional action to avoid unfavorable outcomes for the patient. Objective: To understand the nurses' perception of care related to extravasation of antineoplastic drugs. Method: This is a descriptive-exploratory field study with a qualitative approach; it was carried out with fifteen nurses who work in the outpatient and adult oncology wards of a philanthropic hospital located in Recife/Pernambuco, Brazil. Data were collected between January and December 2020 through interviews and underwent thematic-category content analysis. Results: Two categories emerged: Preventive Care: from the identification of risk factors to the patient and health team education; and Direct Care: from the identification of the occurrence to the institutional management of the event. Conclusion: It was understood that the nurse's perception highlights the importance of care planning, including immediate intervention, event registration, and patient follow-up after extravasation, to perform specialized care and with greater safety.

Extravasation of Noncytotoxic Agents: Skin Injury and Risk Classification.

Extravasations are common manifestations of iatrogenic injuries associated with intravenous therapy. Cytotoxic agents are already subject to a relatively well-defined management strategy in healthcare institutions and classified into three groups according to the extent of damage from extravasation: vesicants, irritants, and non-tissue-damaging agents. Therefore, careful monitoring and initial treatment according to the severity of the skin injury decreases the incidence of extravasation injury. In contrast, high osmolarity, acidic or alkaline, and/or vasoconstrictive activity have all been suggested as possible causes of tissue injury due to the extravasation of noncytotoxic agents. However, the severity of the injuries has not been classified. Therefore, due to a lack of awareness, case reports of severe extravasation injury caused by noncytotoxic agents are increasing. In this paper, we review case reports and animal experiments and classify the severity of extravasation injury by noncytotoxic agents into three categories. Parallel to cytotoxic agents, the classification provides appropriate warning of possible injury severity, helping medical personnel better understand the severity of tissue damage and prevent injury severity during extravasation.

Early post-endovascular treatment contrast extravasation on dual-energy CT is associated with clinical and radiological stroke outcomes: A 10-year single-centre experience.

OBJECTIVE: To determine the association between early post-endovascular treatment (EVT) contrast extravasation (CE) on dual-energy CT (DECT) and stroke outcomes. METHODS: EVT records in 2010-2019 were screened. Exclusion criteria included the occurrence of immediate post-procedural intracranial haemorrhage (ICH). Hyperdense areas on iodine overlay maps were scored according to the Alberta Stroke Programme Early CT Score (ASPECTS), thus forming a CE-ASPECTS. Maximum parenchymal iodine concentration and maximum iodine concentration relative to the torcula were recorded. Follow-up imaging was reviewed for ICH. The primary outcome measure was the modified Rankin Scale (mRS) at 90 days. RESULTS: Out of 651 records, 402 patients were included. CE was found in 318 patients (79%). Thirty-five patients developed ICH on follow-up imaging. Fourteen ICHs were symptomatic. Stroke progression occurred in 59 patients. Multivariable regression showed a significant association between decreasing CE-ASPECTS and the mRS at 90 days (adjusted (a)cOR: 1.10, 95% CI: 1.03-1.18), NIHSS at 24-48 h (aß: 0.57, 95% CI: 0.29-0.84), stroke progression (aOR: 1.14, 95% CI: 1.03-1.26) and ICH (aOR: 1.21, 95% CI: 1.06-1.39), but not symptomatic ICH (aOR 1.19, 95% CI: 0.95-1.38). Iodine concentration was significantly associated with the mRS (acOR: 1.18, 95% CI: 1.06-1.32), NIHSS (aß: 0.68, 95% CI: 0.30-1.06), ICH (aOR: 1.37, 95% CI: 1.04-1.81) and symptomatic ICH (aOR: 1.19, 95% CI: 1.02-1.38), but not stroke progression (aOR: 0.99, 95% CI: 0.86-1.15). Results of the analyses with relative iodine concentration were similar and did not improve prediction. CONCLUSIONS: CE-ASPECTS and iodine concentration are both associated with short- and long-term stroke outcomes. CE-ASPECTS is likely a better predictor for stroke progression.