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      <div class="highwire-cite-overline"><span  class="highwire-cite-metadata-article-type highwire-cite-metadata">Letter</span><span class="separator-pipe"></span><span  class="highwire-cite-metadata-art-cat highwire-cite-metadata"><span class="wrapper">LETTER</span></span></div>
  
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      <h1 class="highwire-cite-title" id="page-title">Acute Stroke Imaging in Transfer Patients Who Received Recent Intravenous Iodinated Contrast at an Outside Facility: An Unrecognized Problem That Deserves More Attention</h1>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0">E. Gulko</span>, <span class="highwire-citation-author" data-delta="1">S. Ali</span>, <span class="highwire-citation-author" data-delta="2">J. Schefflein</span>, <span class="highwire-citation-author" data-delta="3">H. Mehta</span> and <span class="highwire-citation-author" data-delta="4">W. Gomes</span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">June 2021,  </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">42 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(6) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E33; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata">DOI: https://doi.org/10.3174/ajnr.A7041 </span></div>
  
  
  
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<div id="hw-article-author-popups-top-node-91374--6844543138" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">E. Gulko </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>Division of Neuroradiology, Department of RadiologyWestchester Medical CenterValhalla, New York</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=E.%2BGulko%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Gulko%20E&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AE.%2BGulko%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0002-3163-6576" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for E. Gulko</a></li></ul></div><div class="author-tooltip-1"><div class="author-tooltip-name">S. Ali </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>Division of Neuroradiology, Department of RadiologyWestchester Medical CenterValhalla, New York</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=S.%2BAli%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Ali%20S&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AS.%2BAli%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0003-4957-9087" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for S. Ali</a></li></ul></div><div class="author-tooltip-2"><div class="author-tooltip-name">J. Schefflein </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>Division of Neuroradiology, Department of RadiologyWestchester Medical CenterValhalla, New York</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=J.%2BSchefflein%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Schefflein%20J&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AJ.%2BSchefflein%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0002-3096-9643" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for J. Schefflein</a></li></ul></div><div class="author-tooltip-3"><div class="author-tooltip-name">H. Mehta </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>Division of Neuroradiology, Department of RadiologyWestchester Medical CenterValhalla, New York</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=H.%2BMehta%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Mehta%20H&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AH.%2BMehta%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0002-5018-216X" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for H. Mehta</a></li></ul></div><div class="author-tooltip-4"><div class="author-tooltip-name">W. Gomes </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>Division of Neuroradiology, Department of RadiologyWestchester Medical CenterValhalla, New York</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=W.%2BGomes%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Gomes%20W&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link"><a href="/search/author1%3AW.%2BGomes%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li><li class="author-orcid-link last"><a href="https://orcid.org/0000-0002-5046-1505" target="_blank" class="" data-icon-position="" data-hide-link-title="0">ORCID record for W. Gomes</a></li></ul></div></div></div>  </div>

  
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    <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" data-highwire-cite-ref-tooltip-instance="highwire_reflinks_tooltip" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article fulltext-view "><span class="highwire-journal-article-marker-start"></span><p id="p-1">We read with great interest the recent article by Copelan et al<sup><a id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1</a></sup> titled, “Recent Administration of Iodinated Contrast Renders Core Infarct Estimation Inaccurate Using RAPID Software.” In a cohort of patients with acute stroke who received recent intravenous iodinated contrast as part of another imaging study, the authors demonstrated that the rapid processing of perfusion and diffusion (RAPID; iSchemaView) CTP platform may underestimate the core infarct size. This article importantly highlights inherent challenges present in interpreting scans for patients with acute stroke transferred from outside facilities who underwent recent CT imaging with iodinated contrast.</p><p id="p-2">We experienced a different challenge while interpreting scans for transferred patients with stroke who also received recent iodinated contrast at the outside facility.<sup><a id="xref-ref-2-1" class="xref-bibr" href="#ref-2">2</a></sup> We observed parenchymal hyperdensities, likely related to contrast enhancement of acute infarcts. These parenchymal hyperdensities limited our ability to confidently exclude intracranial hemorrhage, and we described using dual-layer spectral imaging to address this problem. Nevertheless, these challenges collectively bring to light the phenomenon of recent intravenous contrast administration hindering interpretation of acute stroke examinations after a patient's arrival to a tertiary care center for potential mechanical thrombectomy. Despite this, sparse literature exists to investigate these issues. As the authors have shown that recent contrast administration may underestimate the core infarct size with the RAPID software, we postulate that a similar phenomenon may result in overestimation of the calculated ASPECTS.</p><p id="p-3">Evaluation for intracranial hemorrhage, ASPECTS decay, and perfusion abnormalities is paramount for appropriate patient selection for mechanical thrombectomy after interfacility transfer. Administration of contrast material at the first facility may limit this ability at the recipient facility. We thank the authors for their important work, and we feel that additional studies are essential to address these issues.</p><div class="section ref-list" id="ref-list-1"><h2 class="">References</h2><ol class="cit-list ref-use-labels"><li><span class="ref-label">1.</span><a class="rev-xref-ref" href="#xref-ref-1-1" title="View reference 1. in text" id="ref-1">↵</a><div class="cit ref-cit ref-journal" id="cit-42.6.E33.1" data-doi="10.3174/ajnr.A6908"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Copelan</span>  <span class="cit-name-given-names">AZ</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Smith</span>  <span class="cit-name-given-names">ER</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Drocton</span>  <span class="cit-name-given-names">GT</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Recent administration of iodinated contrast renders core infarct estimation inaccurate using RAPID software</span>. <abbr class="cit-jnl-abbrev">AJNR Am J Neuroradiol</abbr> <span class="cit-pub-date">2020</span>;<span class="cit-vol">41</span>:<span class="cit-fpage">2235</span>–<span class="cit-lpage">42</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.3174/ajnr.A6908</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>33214184</span></cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiYWpuciI7czo1OiJyZXNpZCI7czoxMDoiNDEvMTIvMjIzNSI7czo0OiJhdG9tIjtzOjE5OiIvYWpuci80Mi82L0UzMy5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-abstract">Abstract</span><span class="cit-sep cit-reflinks-variant-name-sep">/</span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li><li><span class="ref-label">2.</span><a class="rev-xref-ref" href="#xref-ref-2-1" title="View reference 2. in text" id="ref-2">↵</a><div class="cit ref-cit ref-journal" id="cit-42.6.E33.2" data-doi="10.1016/j.clinimag.2020.06.046"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Gulko</span>  <span class="cit-name-given-names">E</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Ali</span>  <span class="cit-name-given-names">S</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Gomes</span>  <span class="cit-name-given-names">W</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Differentiation of hemorrhage from contrast enhancement using dual-layer spectral CT in patients transferred for acute stroke</span>. <abbr class="cit-jnl-abbrev">Clin Imaging</abbr> <span class="cit-pub-date">2021</span>;<span class="cit-vol">69</span>:<span class="cit-fpage">75</span>–<span class="cit-lpage">78</span><span class="cit-pub-id-sep cit-pub-id-doi-sep"> </span><span class="cit-pub-id cit-pub-id-doi"><span class="cit-pub-id-scheme-doi">doi:</span>10.1016/j.clinimag.2020.06.046</span><span class="cit-pub-id-sep cit-pub-id-pmid-sep"> </span><span class="cit-pub-id cit-pub-id-pmid"><span class="cit-pub-id-scheme-pmid">pmid:</span>32683139</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1016/j.clinimag.2020.06.046&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a><a href="/lookup/external-ref?access_num=32683139&amp;link_type=MED&amp;atom=%2Fajnr%2F42%2F6%2FE33.atom" class="cit-ref-sprinkles cit-ref-sprinkles-medline"><span>PubMed</span></a></div></div></li></ol></div><ul class="copyright-statement"><li class="fn" id="copyright-statement-1">© 2021 by American Journal of Neuroradiology</li></ul><span class="highwire-journal-article-marker-end"></span></div><span class="related-urls"></span></div></div>  </div>

  
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        	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-volume highwire-cite-metadata">Vol. 42</span>, <span  class="highwire-cite-metadata-issue highwire-cite-metadata">Issue 6 </span><div  class="highwire-cite-metadata-pubdate highwire-cite-metadata">1 Jun 2021 </div></div>
      
      
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    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">Jun 2021, </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">42 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(6) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E33; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata"><span class="label">DOI:</span> 10.3174/ajnr.A7041 </span></div>
  
  
  
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      <div class="highwire-cite-title">Acute Stroke Imaging in Transfer Patients Who Received Recent Intravenous Iodinated Contrast at an Outside Facility: An Unrecognized Problem That Deserves More Attention</div>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0"><span class="nlm-given-names">E.</span> <span class="nlm-surname">Gulko</span></span>, <span class="highwire-citation-author" data-delta="1"><span class="nlm-given-names">S.</span> <span class="nlm-surname">Ali</span></span>, <span class="highwire-citation-author" data-delta="2"><span class="nlm-given-names">J.</span> <span class="nlm-surname">Schefflein</span></span>, <span class="highwire-citation-author" data-delta="3"><span class="nlm-given-names">H.</span> <span class="nlm-surname">Mehta</span></span>, <span class="highwire-citation-author" data-delta="4"><span class="nlm-given-names">W.</span> <span class="nlm-surname">Gomes</span></span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">Jun 2021, </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">42 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(6) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E33; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata"><span class="label">DOI:</span> 10.3174/ajnr.A7041 </span></div>
  
  
  
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