Letter by Murai et al Regarding Article, “Spot Sign in Acute Intracerebral Hemorrhage in Dynamic T1-Weighted Magnetic Resonance Imaging”

MRI spot sign in acute intracerebral hemorrhage: an independent biomarker of hematoma expansion and poor functional outcome

BACKGROUND

In acute intracerebral hemorrhage (ICH), the prognostic value of the MRI spot sign on hematoma expansion (HE) and poor functional outcome is poorly known.

METHODS

We retrospectively included patients admitted over a 4-year period for an acute ICH in a single institution using MRI as the first-line imaging tool. The presence and number of MRI spot signs on contrast-enhanced T1-weighted imaging was evaluated by one neuroradiologist, blinded from outcomes. The primary outcome was HE, defined as > 6 mL or > 33% ICH volume growth from initial MRI to 24-48 h follow-up imaging; the secondary outcome was poor 3-month modified Rankin score (4-6).

RESULTS

Overall, 147 patients were included, and 62% had a spot sign. Among the 130 patients with follow-up imaging, 24% experienced HE. HE occurred in 6%, 21% and 43% patients with 0, 1 and ≥ 2 spots, respectively (P < 0.001). The MRI spot sign was independently associated with HE (adjusted OR 6.15 [95% CI 1.60-23.65]; P = 0.008), with a dose-dependent effect. The negative and positive predictive values of the spot sign for HE were 0.94 and 0.35, respectively. Poor functional outcome occurred in 27%, 32% and 71% patients with 0, 1 and ≥ 2 spots, respectively (P < 0.001). In multivariable analysis, the presence of ≥ 2 spots was independently associated with poor functional outcome (adjusted OR 3.67 [95% CI 1.21-11.10]; P = 0.024).

CONCLUSION

The MRI spot sign is an independent biomarker of HE, and the presence of ≥ 2 spots is independently associated with poor 3-month outcome. The lack of spot sign is highly predictive of a favorable evolution.

Spot Sign in Acute Intracerebral Hemorrhage in Magnetic Resonance Imaging: A Case Report and Review of the Literature

INTRODUCTION

Intracranial hemorrhage (ICH) is associated with significant mortality and morbidity. Current treatment paradigms focus on correcting hypertension and coagulopathy to prevent hematoma expansion. Magnetic resonance imaging (MRI) is becoming more common in the hyperactive phase of ICH management. The finding of contrast extravasation (ie, spot sign) on MRI may be a marker of active bleeding. We present a case of MRI spot sign and review of the literature.

CASE REPORT

We present a patient on oral coumadin for history of deep venous thrombosis and pulmonary embolus who presented with a right basal ganglia hemorrhage. She had a computed tomography angiography showing contrast extravasation and also had a hyperacute MRI showing similar contrast extravasation. Follow-up imaging showed hematoma enlargement.

DISCUSSION

We present here a case of corroboration of the computed tomography angiography spot sign with the MRI spot sign. The prognostic value of the MRI spot sign is unclear. Future studies should evaluate the prognostic value of the hyperacute MRI in ICH management.