Meta-Analysis of Predictive Significance of the Black Hole Sign for Hematoma Expansion in Intracerebral Hemorrhage

The clinical potential of radiomics to predict hematoma expansion in spontaneous intracerebral hemorrhage: a narrative review

Spontaneous intracerebral hemorrhage (sICH) is associated with significant morbidity and mortality, with subsequent hematoma expansion (HE) linked to worse neurologic outcomes. Accurate, real-time predictions of the risk of HE could enable tailoring management-including blood pressure control or surgery-based on individual patient risk. Although multiple radiographic markers of HE have been proposed based on standard imaging, their clinical utility remains limited by a reliance on subjective interpretation of often ambiguous findings and a poor overall predictive power. Radiomics refers to the quantitative analysis of medical images that can be combined with machine-learning algorithms to identify predictive features for a chosen clinical outcome with a granularity beyond human limitations. Emerging data have supported the potential utility of radiomics in the prediction of HE after sICH. In this review, we discuss the current clinical management of sICH, the impact of HE and standard imaging predictors, and finally, the current data and potential future role of radiomics in HE prediction and management of patients with sICH.

Clinical characteristics of spontaneous intracranial basal ganglia hemorrhage and risk factors for hematoma expansion in the plateaus of China

Background and purpose

The clinical features of intracranial cerebral hemorrhage (ICH) and the risk factors for hematoma expansion (HE) have been extensively studied. However, few studies have been performed in patients who live on a plateau. The natural habituation and genetic adaptation have resulted in differences in disease characteristics. The purpose of this study was to investigate the differences and consistency of clinical and imaging characteristics of patients in the plateaus of China compared with the plains, and to analyze the risk factors for HE of intracranial hemorrhage in the plateau patients.

Methods

From January 2020 to August 2022, we undertook a retrospective analysis of 479 patients with first-episode spontaneous intracranial basal ganglia hemorrhage in Tianjin and Xining City. The clinical and radiologic data during hospitalization were analyzed. Univariate and multivariate logistic regression analyzes were used to assess the risk factors for HE.

Results

HE occurred in 31 plateau (36.0%) and 53 plain (24.2%) ICH patients, and HE was more likely to occur in the plateau patients compared with the plain (p = 0.037). The NCCT images of plateau patients also showed heterogeneity of hematoma imaging signs, and the incidence of blend signs (23.3% vs. 11.0%, p = 0.043) and black hole signs (24.4% vs. 13.2%, p = 0.018) was significantly higher than in the plain. Baseline hematoma volume, black hole sign, island sign, blend sign, and PLT and HB level were associated with HE in the plateau. Baseline hematoma volume and the heterogeneity of hematoma imaging signs were independent predictors of HE in both the plain and plateau.

Conclusion

Compared with the plain, ICH patients in the plateau were more prone to HE. The patients showed the same heterogeneous signs on the NCCT images as in the plain, and also had predictive value for HE.

The "SALPARE study" of spontaneous intracerebral haemorrhage-part 2-early CT predictors of outcome in ICH: keeping it simple

BACKGROUND

The aim of this study was to investigate the prognostic role of hematoma characteristics and hematoma expansion (HE) in patients with spontaneous intracerebral hemorrhage (ICH).

METHODS

This multicenter prospective cohort study enrolled consecutive adult patients with non-traumatic ICH admitted to three Italian academic hospitals (Salerno, Padova, Reggio Emilia) over a 2-year period. Early noncontrast CT (NCCT) features of the hematoma, including markers of HE, and 3-month outcome were recorded. Multivariable logistic regression analysis was performed to identify predictors of poor outcome.

RESULTS

A total of 682 patients were included in the study [mean age: 73 ± 14 years; 316 (46.3%) females]. Pontine and massive hemorrhage, intraventricular bleeding, baseline hematoma volume > 15 mL, blend sign, swirl sign, margin irregularity ≥ 4, density heterogeneity ≥ 3, hypodensity ≥ 1, island sign, satellite sign, and black hole sign were associated with a higher risk of mortality and disability. However, at multivariate analysis only initial hematoma volume (OR 29.71) proved to be an independent predictor of poor functional outcome at 3 months.

CONCLUSION

Simple hematoma volume measured on baseline CT best identifies patients with a worse outcome, while early NCCT markers of HE do not seem to add any clinically significant information.

Computed tomography in acute intracerebral hemorrhage: neuroimaging predictors of hematoma expansion and outcome

Intracerebral hemorrhage (ICH) accounts for 10–20% of all strokes worldwide and is associated with serious outcomes, including a 30-day mortality rate of up to 40%. Neuroimaging is pivotal in diagnosing ICH as early detection and determination of underlying cause, and risk for expansion/rebleeding is essential in providing the correct treatment. Non-contrast computed tomography (NCCT) is the most used modality for detection of ICH, identification of prognostic markers and measurements of hematoma volume, all of which are of major importance to predict outcome. The strongest predictors of 30-day mortality and functional outcome for ICH patients are baseline hematoma volume and hematoma expansion. Even so, exact hematoma measurement is rare in clinical routine practice, primarily due to a lack of tools available for fast, effective, and reliable volumetric tools. In this educational review, we discuss neuroimaging findings for ICH from NCCT images, and their prognostic value, as well as the use of semi-automatic and fully automated hematoma volumetric methods and assessment of hematoma expansion in prognostic studies.

Computed Tomography Imaging Predictors of Intracerebral Hemorrhage Expansion

PURPOSE OF REVIEW

Hematoma expansion (HE) is strongly associated with poor clinical outcome and is a compelling target for improving outcome after intracerebral hemorrhage (ICH). Non-contrast computed tomography (NCCT) is widely used in clinical practice due to its faster acquisition at the presence of acute stroke. Recently, imaging markers on NCCT are increasingly used for predicting HE. We comprehensively review the current evidence on HE prediction using NCCT and provide a summary for assessment of these markers in future research studies.

RECENT FINDINGS

Predictors of HE on NCCT have been described in reports of several studies. The proposed markers, including swirl sign, blend sign, black hole sign, island sign, satellite sign, and subarachnoid extension, were all significantly associated with HE and poor outcome in their small sample studies after ICH. In summary, the optimal management of ICH remains a therapeutic dilemma. Therefore, using NCCT markers to select patients at high risk of HE is urgently needed. These markers may allow rapid identification and provide potential targets for anti-HE treatments in patients with acute ICH.

Comparison of Black Hole Sign, Satellite Sign, and Iodine Sign to Predict Hematoma Expansion in Patients with Spontaneous Intracerebral Hemorrhage

PURPOSE

To discretely and collectively compare black hole sign (BHS) and satellite sign (SS) with recently introduced gemstone spectral imaging-based iodine sign (IS) for predicting hematoma expansion (HE) in spontaneous intracerebral hemorrhage (SICH).

METHODS

This retrospective study includes 90 patients from 2017 to 2019 who underwent both spectral computed tomography angiography (CTA) as well as noncontrast computed tomography (NCCT) within 6 hours of SICH onset along with subsequent follow-up NCCT scanned within 24 hours. We named the presence of any of BHS or SS as any NCCT sign. Two independent reviewers analyzed all the HE predicting signs. Receiver-operator characteristic curve analysis and logistic regression were performed to compare the predictive performance of HE.

RESULTS

A total of 61 patients had HE, out of which IS was seen in 78.7% (48/61) while BHS and SS were seen in 47.5% (29/61) and 41% (25/61), respectively. The area under the curve for BHS, SS, and IS was 63.4%, 67%, and 82.4%, respectively, while for any NCCT sign was 71.5%. There was no significant difference between IS and any NCCT sign (P = 0.108). Multivariate analysis showed IS (odds ratio 68.24; 95% CI 11.76-396.00; P < 0.001) and any NCCT sign (odds ratio 19.49; 95% CI 3.99-95.25; P < 0.001) were independent predictors of HE whereas BHS (odds ratio 0.34; 95% CI 0.01-38.50; P = 0.534) and SS (odds ratio 4.54; 95% CI 0.54-38.50; P = 0.165) had no significance.

CONCLUSION

The predictive accuracy of any NCCT sign was better than that of sole BHS and SS. Both any NCCT sign and IS were independent predictors of HE. Although IS had higher predictive accuracy, any NCCT sign may still be regarded as a fair predictor of HE when CTA is not available.

A Meta-analysis of the Predictive Significance of the Island Sign for Hematoma Expansion in Intracerebral Hemorrhage

BACKGROUND

The island sign of non-contrast computed tomography is a risk factor for hematoma expansion (HE) after spontaneous intracerebral hemorrhage, but has inconsistent conclusions. A meta-analysis was performed to investigate the predictive accuracy of island sign for HE.

METHODS

A systematic review of published literature on island sign and hematoma expansion was conducted. The pooled sensitivity, specificity, and summary receiver operating characteristics curve (SROC) were generated. The publication bias was assessed by Deeks' funnel plot asymmetry test.

RESULTS

Nine studies with a total of 2939 patients were included in the present study. The pooled sensitivity and specificity of island sign for predicting hematoma expansion was 0.50 and 0.89, respectively. The area under the curve was 0.73 in the SROC curve. There was no significant publication bias.

CONCLUSIONS

This meta-analysis suggests that island sign of non-contrast computed tomography has a good predictive accuracy for hematoma enlargement in intracerebral hemorrhage.

The predictive accuracy of satellite sign for hematoma expansion in intracerebral hemorrhage: A meta-analysis

BACKGROUND AND PURPOSE

Satellite sign is a novel neuroimaging marker for predicting hematoma expansion (HE), which is closely related to unfavorable prognosis in patients with spontaneous intracerebral hemorrhage (ICH). However, the predictive value of satellite sign varied according to previous studies. Thus, we conduct this meta-analysis to systematically review the application value of satellite sign in related studies.

METHODS

We searched the literature in PubMed, Embase, and Web of Science from inception to April 10, 2020. Effect values, including sensitivity, specificity, and positive and negative likelihood ratio were pooled to assess the diagnostic value of satellite sign for HE in patients with ICH.

RESULTS

The meta-analysis included five studies with a total of 1493 patients. Results showed that the pooled diagnostic sensitivity and specificity were 0.50 (95 % CI, 0.31-0.70) and 0.71 (95 % CI, 0.56-0.83), respectively. In addition, the pooled positive and negative likelihood ratios were 1.7 (95 % CI, 1.5-2.1) and 0.70 (95 % CI, 0.54-0.89), respectively. No significant publication bias was found.

CONCLUSION

Satellite sign exhibited moderate sensitivity and specificity for predicting HE in patients with ICH. Further studies are needed to explore its value in clinical application.

Noncontrast Computed Tomography Signs as Predictors of Hematoma Expansion, Clinical Outcome, and Response to Tranexamic Acid in Acute Intracerebral Hemorrhage

Supplemental Digital Content is available in the text.

Blend, black hole, island signs, and hypodensities are reported to predict hematoma expansion in acute intracerebral hemorrhage. We explored the value of these noncontrast computed tomography signs in predicting hematoma expansion and functional outcome in our cohort of intracerebral hemorrhage.