Effect of CTA Tube Current on Spot Sign Detection and Accuracy for Prediction of Intracerebral Hemorrhage Expansion

Using Noncontrast Computed Tomography to Improve Prediction of Intracerebral Hemorrhage Expansion

BACKGROUND

Noncontrast computed tomography hypodensities are a validated predictor of hematoma expansion (HE) in intracerebral hemorrhage and a possible alternative to the computed tomography angiography (CTA) spot sign but their added value to available prediction models remains unclear. We investigated whether the inclusion of hypodensities improves prediction of HE and compared their added value over the spot sign.

METHODS

Retrospective analysis of patients admitted for primary spontaneous intracerebral hemorrhage at the following 8 university hospitals in Boston, US (1994-2015, prospective), Hamilton, Canada (2010-2016, retrospective), Berlin, Germany (2014-2019, retrospective), Chongqing, China (2011-2015, retrospective), Pavia, Italy (2017-2019, prospective), Ferrara, Italy (2010-2019, retrospective), Brescia, Italy (2020-2021, retrospective), and Bologna, Italy (2015-2019, retrospective). Predictors of HE (hematoma growth >6 mL and/or >33% from baseline to follow-up imaging) were explored with logistic regression. We compared the discrimination of a simple prediction model for HE based on 4 predictors (antitplatelet and anticoagulant treatment, baseline intracerebral hemorrhage volume, and onset-to-imaging time) before and after the inclusion of noncontrast computed tomography hypodensities, using receiver operating characteristic curve and De Long test for area under the curve comparison.

RESULTS

A total of 2465 subjects were included, of whom 664 (26.9%) had HE and 1085 (44.0%) had hypodensities. Hypodensities were independently associated with HE after adjustment for confounders in logistic regression (odds ratio, 3.11 [95% CI, 2.55-3.80]; P<0.001). The inclusion of noncontrast computed tomography hypodensities improved the discrimination of the 4 predictors model (area under the curve, 0.67 [95% CI, 0.64-0.69] versus 0.71 [95% CI, 0.69-0.74]; P=0.025). In the subgroup of patients with a CTA available (n=895, 36.3%), the added value of hypodensities remained statistically significant (area under the curve, 0.68 [95% CI, 0.64-0.73] versus 0.74 [95% CI, 0.70-0.78]; P=0.041) whereas the addition of the CTA spot sign did not provide significant discrimination improvement (area under the curve, 0.74 [95% CI, 0.70-0.78]).

CONCLUSIONS

Noncontrast computed tomography hypodensities provided a significant added value in the prediction of HE and appear a valuable alternative to the CTA spot sign. Our findings might inform future studies and suggest the possibility to stratify the risk of HE with good discrimination without CTA.

Neuroimaging of Acute Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) accounts for 10% to 20% of all strokes worldwide and is associated with high morbidity and mortality. Neuroimaging is clinically important for the rapid diagnosis of ICH and underlying etiologies, but also for identification of ICH expansion, often as-sociated with an increased risk for poor outcome. In this context, rapid assessment of early hema-toma expansion risk is both an opportunity for therapeutic intervention and a potential hazard for hematoma evacuation surgery. In this review, we provide an overview of the current literature surrounding the use of multimodal neuroimaging of ICH for etiological diagnosis, prediction of early hematoma expansion, and prognostication of neurological outcome. Specifically, we discuss standard imaging using computed tomography, the value of different vascular imaging modalities to identify underlying causes and present recent advances in magnetic resonance imaging and computed tomography perfusion.

Different criteria for defining "spot sign" in intracerebral hemorrhage show different abilities to predict hematoma expansion and clinical outcomes: a systematic review and meta-analysis

The "spot sign" is a well-known radiological marker used for predicting hematoma expansion and clinical outcomes in patients with intracerebral hemorrhage (ICH). We performed a meta-analysis to assess the predictive accuracy of spot sign, depending on the criteria used to identify them.We conducted a systematic review of clinical studies that clearly stated their definition of spot sign and that were indexed in the Cochrane Library, MEDLINE, EMBASE, and the China National Knowledge Infrastructure databases. We collected data on computed tomography (CT) parameters, spot sign diagnostic criteria, hematoma expansion, and clinical outcomes.Based on the eligibility criteria, we included 17 studies in this systematic review. CT imaging modality, type, time from symptom onset to CT, time from contrast infusion to scan, slice thickness, tube current, and tube electric discharge showed variation across studies. Three different definitions of the spot sign were applied: (1) a hyperdense spot within the hematoma; (2) one or more focal areas/regions of contrast pooling of any size and morphology that occurred within a hemorrhage, were discontinuous from the normal or abnormal vasculature adjacent to the hemorrhage, and showed an attenuation rate ≥ 120 UH; or (3) serpiginous or spot-like contrast density on CTA images that occurred within the hematoma margin, showed twice the density of the hematoma background, and did not contact vessels outside the hematoma. Three definitions for the spot sign were identified, all of which were associated with hematoma expansion, mortality, and unfavorable functional outcome. Subgroup analyses based on these definitions showed that spot sign identified using the second definition were more likely to be associated with hematoma expansion (OR 18.31, 95% CI 9.11-36.8) and unfavorable functional outcomes (OR 8.78, 95% CI 3.24-23.79), while those identified using the third definition were associated with increased risk of mortality (OR 6.88, 95% CI 1.43-33.13).Clinical studies identify spot sign using different CT protocols and criteria. These differences affect the ability of spot sign to predict hematoma expansion and clinical outcomes in ICH patients.

Dual-Energy CT Angiography Improves Accuracy of Spot Sign for Predicting Hematoma Expansion in Intracerebral Hemorrhage

Background and Purpose

Spot sign (SS) on computed tomography angiography (CTA) is associated with hematoma expansion (HE) and poor outcome after intracerebral hemorrhage (ICH). However, its predictive performance varies across studies, possibly because differentiating hyperdense hemorrhage from contrast media is difficult. We investigated whether dual-energy-CTA (DE-CTA), which can separate hemorrhage from iodinated contrast, improves the diagnostic accuracy of SS for predicting HE.

Methods

Primary ICH patients undergoing DE-CTA (both arterial as well as delayed venous phase) and follow-up computed tomography were prospectively included between 2014 and 2019. SS was assessed on both arterial and delayed phase images of the different DE-CTA datasets, i.e., conventional-like mixed images, iodine images, and fusion images. Diagnostic accuracy of SS for prediction of HE was determined on all datasets. The association between SS and HE, and between SS and poor outcome (modified Rankin Scale at 3 months ≥3) was assessed with multivariable logistic regression, using the dataset with highest diagnostic accuracy.

Results

Of 139 included patients, 47 showed HE (33.8%). Sensitivity of SS for HE was 32% (accuracy 0.72) on conventional-like mixed arterial images which increased to 76% (accuracy 0.80) on delayed fusion images. Presence of SS on delayed fusion images was independently associated with HE (odds ratio [OR], 17.5; 95% confidence interval [CI], 6.14 to 49.82) and poor outcome (OR, 3.84; 95% CI, 1.16 to 12.73).

Conclusions

Presence of SS on DE-CTA, in particular on delayed phase fusion images, demonstrates higher diagnostic performance in predicting HE compared to conventional-like mixed imaging, and it is associated with poor outcome.

Correlation between Spot Sign and Intracranial Hemorrhage Expansion on Dual-Phase CT Angiography

Purpose: Expansion of intracranial hemorrhage (ICH) is an important predictor of poor clinical outcome. ICH expansion can be predicted with a spot sign on computed tomographic angiography (CTA). We aimed to evaluate the correlation between spot signs on CTA and ICH expansion on dual-phase CTA. Methods: Patients with spontaneous ICH between January 2017 and April 2019 who underwent an initial CT, dual-phase CTA, and a subsequent CT were retrospectively identified. ICH expansion was defined as volume growth of >33% or >6 mL. We analyzed the presence and change in size of the spot sign in the first phase and second phase CTA. Also, we divided the morphological status of the spot sign, such as a dot-like lesion or linear contrast extravasation, in the first and second phase CTA. Results: A total of 206 patients, including 38 (18.5%) with ICH expansion and 45 (21.8%) with a spot sign, qualified for analysis. Of patients with a spot sign, 26 (57.8%) had ICH expansion on subsequent CT. Increased size of a spot sign in second-phase CTA was more frequent in the ICH expansion group than in the no-expansion group (96.2% vs. 52.6%, p < 0.001). First visualization of a spot sign in the second phase was more common in the no-expansion group than in the ICH expansion group (47.4% vs. 3.8%, p < 0.001). The morphological patterns of a spot sign between the two groups were not significantly different. Conclusion: Spot signs on dual-phase CTA have different sizes and morphological patterns. Increased size of a spot sign in the second phase of CTA can help identify patients at risk for ICH expansion.

Integration of Computed Tomographic Angiography Spot Sign and Noncontrast Computed Tomographic Hypodensities to Predict Hematoma Expansion

Background and Purpose- Noncontrast computed tomographic (CT) hypodensities represent an alternative to the CT angiography spot sign (SS) to predict intracerebral hemorrhage (ICH) expansion. However, previous studies suggested that these markers predicted hematoma expansion independently from each other. We investigated whether the integration of SS and hypodensity (HD) improved the stratification of ICH expansion risk. Methods- A single-center cohort of consecutive patients with ICH was retrospectively analyzed. Patients with available CT angiography, baseline, and follow-up noncontrast CT images available were included. Trained readers reviewed all the images for SS and HD presence, and the study population was classified into 4 groups: SS and HD negative (SS-HD-), SS positive only (SS+HD-), HD positive only (SS-HD+), and SS and HD positive (SS+HD+). ICH expansion was defined as hematoma growth >33% or >6 mL. The association between SS and HD presence and ICH expansion was investigated with multivariable logistic regression. Results- A total of 745 subjects qualified for the analysis (median age, 73 years; 54.1% men). The rates of ICH expansion were 9.3% in SS-HD-, 25.8% in SS+HD-, 27.4% in SS-HD+, and 55.6% in SS+HD+ patients ( P<0.001). After adjustment for potential confounders and keeping SS-HD- subjects as reference, the risk of ICH expansion was increased in SS+HD- and SS-HD+ patients (odds ratio, 2.93, P=0.002 and odds ratio, 3.02, P<0.001, respectively). SS+HD+ subjects had the highest risk of hematoma growth (odds ratio, 9.50; P<0.001). Conclusions- Integration of SS and HD improves the stratification of hematoma growth risk and may help the selection of patients with ICH for antiexpansion treatment in clinical trials.

Standards for Detecting, Interpreting, and Reporting Noncontrast Computed Tomographic Markers of Intracerebral Hemorrhage Expansion

Significant hematoma expansion (HE) affects one-fifth of people within 24 hours after acute intracerebral hemorrhage (ICH), and its prevention is an appealing treatment target. Although the computed tomography (CT)-angiography spot sign predicts HE, only a minority of ICH patients receive contrast injection. Conversely, noncontrast CT (NCCT) is used to diagnose nearly all ICH, so NCCT markers represent a widely available alternative for prediction of HE. However, different NCCT signs describe similar features, with lack of consensus on the optimal image acquisition protocol, assessment, terminology, and diagnostic criteria. In this review, we propose practical guidelines for detecting, interpreting, and reporting NCCT predictors of HE. ANN NEUROL 2019;86:480-492.

Meta-Analysis of Accuracy of the Spot Sign for Predicting Hematoma Growth and Clinical Outcomes

Background and Purpose- The computed tomography angiographic spot sign refers to contrast leakage within intracerebral hemorrhage (ICH). It has been proposed as a surrogate radiological marker for ICH growth. We conducted a meta-analysis to study the accuracy of the spot sign for predicting ICH growth and mortality. Methods- PubMed, Medline, conference proceedings, and article references in English up to June 2017 were searched for studies reporting "computed tomography angiography" and "spot sign" or "intracerebral hemorrhage" and "spot sign." Each study was ranked on 27 criteria resulting in a quality rating score. Bivariate random effect meta-analysis was used to calculate positive and negative likelihood ratios and area under summary receiver operating characteristics curve for ICH growth and mortality. Hematoma growth was defined using the change in ≥6 mL or ≥33% increase in volume. Results- There were 26 studies describing 5085 patients, including 15 studies not used in previous meta-analyses. Positive likelihood ratio and negative likelihood ratio for ICH growth were 4.85 (95% CI, 3.85-6.02; I²=76.1%) and 0.49 (95% CI, 0.40-0.58) and mortality were 4.65 (95% CI, 3.67-5.90) and 0.55 (95% CI, 0.40-0.69), respectively. For ICH growth, the pooled sensitivity was 0.57 (95% CI, 0.49-0.64) and pooled false positive rate was 0.12 (95% CI, 0.09-0.14). The post-test probability of ICH growth was 0.57. The area under the curve for ICH growth and mortality was 0.86 and 0.87 (CIs are not provided in bivariate method). Meta-regression showed sensitivity of the test to decline significantly with subsequent year of publication (β=-0.148; 95% CI, -0.295 to -0.001; P=0.05). Higher quality assessment is associated with lower false positive rate (β=-0.074; 95% CI, -0.126 to -0.022; P=0.006). Conclusions- The high area under the curve potentially suggests that the spot sign can predict hematoma growth and mortality. Caution is recommended in its application given the heterogeneity across studies, which is appropriate given the data.

Diagnostic value of swirl sign on noncontrast computed tomography and spot sign on computed tomographic angiography to predict intracranial hemorrhage expansion

OBJECTIVE

Intracranial hemorrhage (ICH) expansion is a predictor of poor clinical outcome. ICH expansion can be predicted with a swirl sign on noncontrast computed tomography (NCCT) and/or a spot sign on computed tomographic angiography (CTA). In this study, we aimed to evaluate the diagnostic value of a swirl sign and a spot sign in identifying hematoma expansion.

PATIENTS AND METHODS

Patients with spontaneous ICH between January 2013 and August 2018 who underwent an initial NCCT and CTA, and a subsequent NCCT at a single center were retrospectively identified. Two experienced neuroradiologists reviewed all images for swirl sign and spot sign presence using a 4-point scale for receiver-operative characteristic analysis. ICH expansion was defined as volume growth of >33% or >6 mL.

RESULTS

A total of 227 patients, including 54 with ICH expansion, qualified for analysis. For both observers, the area under the curve (AUC) of spot sign was significantly higher than that of swirl sign (observer 1: 0.748 vs. 0.577, p = .002; observer 2: 0.749 vs. 0.589, p = .004). The sensitivities of ICH expansion in patients with a spot sign was significantly higher than patients with a swirl sign (observer 1: 54.1% vs. 28.0%, p = .002; observer 2: 56.9% vs. 30.3%, p = .002). Patients with a spot sign had the highest risk of ICH expansion (odds ratio: observer 1 = 8.14, observer 2 = 9.30, p < 0.001).

CONCLUSIONS

A spot sign on CTA was identified and associated with ICH expansion. A swirl sign on NCCT had a relatively low sensitivity and AUC, and will not be able to replace spot sign on CTA.

Accuracy of spot sign in predicting hematoma expansion and clinical outcome: A meta-analysis

BACKGROUND

Spot sign on computed tomography angiography (CTA) has been reported as a risk factor for hematoma expansion (HE) and poor outcome after intracerebral hemorrhage (ICH). We performed a meta-analysis to investigate the predictive accuracy of spot sign for HE, mortality risk, and poor outcome.

METHODS

We searched PubMed, Embase, and the Cochrane Library for relevant studies. Studies were incorporated if they reported data on relationship between CTA spot sign and HE, mortality or poor outcome.

RESULTS

Twenty-nine studies were pooled in this meta-analysis. The spot sign occurred in 23.4% patients with spontaneous ICH undergoing CTA scans. It showed a sensitivity of 62% (95% confidence interval [CI] 54-69), with a specificity of 88% (95% CI 85-91). Spot sign was related with increased risk of HE (odds ratios [OR] 8.49, 95% CI 7.28-9.90). In the analysis of association between spot sign and outcome, patients with spot sign had a significant higher risk of in-hospital death (OR 5.08, 95% CI 3.16-8.18) and 3-month death (OR 3.80, 95% CI 2.62-5.52). The spot sign was also a predictor of poor outcome at discharge (OR 6.40, 95% CI 3.41-12.03) and at 3 months (OR 4.44, 95% CI 2.33-8.46).

CONCLUSIONS

The overall incidence of CTA spot sign in spontaneous ICH patients is substantial. Spot sign demonstrated a good diagnostic performance in predicting HE and was closely associated with increased risk of death and poor outcome.

Do Intracerebral Hemorrhage Nonexpanders Actually Expand Into the Ventricular Space?

BACKGROUND AND PURPOSE

The computed tomographic angiography spot sign as a predictor of hematoma expansion is limited by its modest sensitivity and positive predictive value. It is possible that hematoma expansion in spot-positive patients is missed because of decompression of intracerebral hemorrhage (ICH) into the ventricular space. We hypothesized that revising hematoma expansion definitions to include intraventricular hemorrhage (IVH) expansion will improve the predictive performance of the spot sign. Our objectives were to determine the proportion of ICH nonexpanders who actually have IVH expansion, determine the proportion of false-positive spot signs that have IVH expansion, and compare the known predictive performance of the spot sign to a revised definition incorporating IVH expansion.

METHODS

We analyzed patients from the multicenter PREDICT ICH spot sign study. We defined hematoma expansion as ≥6 mL or ≥33% ICH expansion or >2 mL IVH expansion and compared spot sign performance using this revised definition with the conventional 6 mL/33% definition using receiver operating curve analysis.

RESULTS

Of 311 patients, 213 did not meet the 6-mL/33% expansion definition (nonexpanders). Only 13 of 213 (6.1%) nonexpanders had ≥2 mL IVH expansion. Of the false-positive spot signs, 4 of 40 (10%) had >2 mL ventricular expansion. The area under the curve for spot sign to predict significant ICH expansion was 0.65 (95% confidence interval, 0.58-0.72), which was no different than when IVH expansion was added to the definition (area under the curve, 0.66; 95% confidence interval, 0.58-0.71).

CONCLUSIONS

Although IVH expansion does indeed occur in a minority of ICH nonexpanders, its inclusion into a revised hematoma expansion definition does not alter the predictive performance of the spot sign.

Intensive Blood Pressure Reduction and Spot Sign in Intracerebral Hemorrhage: A Secondary Analysis of a Randomized Clinical Trial

Importance

The computed tomographic angiography (CTA) spot sign is associated with intracerebral hemorrhage (ICH) expansion and may mark those patients most likely to benefit from intensive blood pressure (BP) reduction.

Objective

To investigate whether the spot sign is associated with ICH expansion across a wide range of centers and whether intensive BP reduction decreases hematoma expansion and improves outcome in patients with ICH and a spot sign.

Design, Setting, and Participants

SCORE-IT (Spot Sign Score in Restricting ICH Growth) is a preplanned prospective observational study nested in the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-II) randomized clinical trial. Participants included consecutive patients with primary ICH who underwent a CTA within 8 hours from onset at 59 sites from May 15, 2011, through December 19, 2015. Data were analyzed for the present study from July 1 to August 31, 2016.

Main Outcomes and Measures

Patients in ATACH-II were randomized to intensive (systolic BP target, <140 mm Hg) vs standard (systolic BP target, <180 mm Hg) BP reduction within 4.5 hours from onset. Expansion of ICH was defined as hematoma growth of greater than 33%, and an unfavorable outcome was defined as a 90-day modified Rankin Scale score of 4 or greater (range, 0-6). The association among BP reduction, ICH expansion, and outcome was investigated with multivariable logistic regression.

Results

A total of 133 patients (83 men [62.4%] and 50 women [37.6%]; mean [SD] age, 61.9 [13.1] years) were included. Of these, 53 (39.8%) had a spot sign, and 24 of 123 without missing data (19.5%) experienced ICH expansion. The spot sign was associated with expansion with sensitivity of 0.54 (95% CI, 0.34-0.74) and specificity of 0.63 (95% CI, 0.53-0.72). After adjustment for potential confounders, intensive BP treatment was not associated with a significant reduction of ICH expansion (relative risk, 0.83; 95% CI, 0.27-2.51; P = .74) or improved outcome (relative risk of 90-day modified Rankin Scale score ≥4, 1.24; 95% CI, 0.53-2.91; P = .62) in spot sign-positive patients.

Conclusions and Relevance

The predictive performance of the spot sign for ICH expansion was lower than in prior reports from single-center studies. No evidence suggested that patients with ICH and a spot sign specifically benefit from intensive BP reduction.

Trial Registration

clinicaltrials.gov Identifier: NCT01176565.

Sex differences in intracerebral hemorrhage expansion and mortality

BACKGROUND AND OBJECTIVE

Due to conflicting results in multiple studies, uncertainty remains regarding sex differences in severity and mortality after intracerebral hemorrhage (ICH). We investigated the impact of sex on ICH severity, expansion, and mortality.

METHODS

We analyzed prospectively collected ICH patients and assessed clinical variables and mortality rate. Mediation analyses were used to examine associations between sex and mortality and sex and hematoma expansion.

RESULTS

2212 patients were investigated, 53.5% male. Men with ICH were younger (72 vs. 77years), had greater smoking and alcohol use, and were more likely to have hypertension, diabetes, hypercholesterolemia and coronary artery disease (all p<0.05). Lobar hemorrhages were more frequent in women (47.6% vs 38.4%, p<0.001). Male sex was a risk factor for hematoma expansion (Odd Ratio (OR) 1.7, 95% confidence interval (CI) 1.15-2.50, p=0.007). Multivariable analysis found that male sex was independently associated with 90-day mortality (OR 2.15 (95% CI 1.46-3.19), p<0.001), and one-year mortality (Hazard Ratio 1.28 (95% CI: 1.09-1.50), p=0.003). Early hematoma expansion mediated a portion of the association between sex and mortality (mediation p=0.02).

CONCLUSIONS

Men with ICH experience a higher risk of both expansion and early and late mortality, even after controlling for known risk factors. Further research is needed to explore the biological mechanisms underlying these observed differences.

Phantom-based standardization of CT angiography images for spot sign detection

PURPOSE

The CT angiography (CTA) spot sign is a strong predictor of hematoma expansion in intracerebral hemorrhage (ICH). However, CTA parameters vary widely across centers and may negatively impact spot sign accuracy in predicting ICH expansion. We developed a CT iodine calibration phantom that was scanned at different institutions in a large multicenter ICH clinical trial to determine the effect of image standardization on spot sign detection and performance.

METHODS

A custom phantom containing known concentrations of iodine was designed and scanned using the stroke CT protocol at each institution. Custom software was developed to read the CT volume datasets and calculate the Hounsfield unit as a function of iodine concentration for each phantom scan. CTA images obtained within 8 h from symptom onset were analyzed by two trained readers comparing the calibrated vs. uncalibrated density cutoffs for spot sign identification. ICH expansion was defined as hematoma volume growth >33%.

RESULTS

A total of 90 subjects qualified for the study, of whom 17/83 (20.5%) experienced ICH expansion. The number of spot sign positive scans was higher in the calibrated analysis (67.8 vs 38.9% p < 0.001). All spot signs identified in the non-calibrated analysis remained positive after calibration. Calibrated CTA images had higher sensitivity for ICH expansion (76 vs 52%) but inferior specificity (35 vs 63%) compared with uncalibrated images.

CONCLUSION

Normalization of CTA images using phantom data is a feasible strategy to obtain consistent image quantification for spot sign analysis across different sites and may improve sensitivity for identification of ICH expansion.

Blood pressure reduction and noncontrast CT markers of intracerebral hemorrhage expansion

OBJECTIVE

To validate various noncontrast CT (NCCT) predictors of hematoma expansion in a large international cohort of ICH patients and investigate whether intensive blood pressure (BP) treatment reduces ICH growth and improves outcome in patients with these markers.

METHODS

We analyzed patients enrolled in the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-II) randomized controlled trial. Participants were assigned to intensive (systolic BP <140 mm Hg) vs standard (systolic BP <180 mm Hg) treatment within 4.5 hours from onset. The following NCCT markers were identified: intrahematoma hypodensities, black hole sign, swirl sign, blend sign, heterogeneous hematoma density, and irregular shape. ICH expansion was defined as hematoma growth >33% and unfavorable outcome was defined as modified Rankin Scale score >3 at 90 days. Logistic regression was used to identify predictors of ICH expansion and explore the association between NCCT signs and clinical benefit from intensive BP treatment.

RESULTS

A total of 989 patients were included (mean age 62 years, 61.9% male), of whom 186/869 experienced hematoma expansion (21.4%) and 361/952 (37.9%) had unfavorable outcome. NCCT markers independently predicted ICH expansion (all p < 0.01) with overall accuracy ranging from 61% to 78% and good interrater reliability (k > 0.6 for all markers). There was no evidence of an interaction between NCCT markers and benefit from intensive BP reduction (all p for interaction >0.10).

CONCLUSIONS

NCCT signs reliably identify ICH patients at high risk of hematoma growth. However, we found no evidence that patients with these markers specifically benefit from intensive BP reduction.

CLINICALTRIALSGOV IDENTIFIER

NCT01176565.

The Accuracy of the Spot Sign and the Blend Sign for Predicting Hematoma Expansion in Patients with Spontaneous Intracerebral Hemorrhage

BACKGROUND Hematoma expansion is associated with poor outcome in intracerebral hemorrhage (ICH) patients. The spot sign and the blend sign are reliable tools for predicting hematoma expansion in ICH patients. The aim of this study was to compare the accuracy of the two signs in the prediction of hematoma expansion. MATERIAL AND METHODS Patients with spontaneous ICH were screened for the presence of the computed tomography angiography (CTA) spot sign and the non-contrast CT (NCCT) blend sign within 6 hours after onset of symptoms. The sensitivity, specificity, and positive and negative predictive values of the spot sign and the blend sign in predicting hematoma expansion were calculated. The accuracy of the spot sign and the blend sign in predicting hematoma expansion was analyzed by receiver-operator analysis. RESULTS A total of 115 patients were enrolled in this study. The spot sign was observed in 25 (21.74%) patients, whereas the blend sign was observed in 22 (19.13%) patients. Of the 28 patients with hematoma expansion, the CTA spot sign was found on admission CT scans in 16 (57.14%) and the NCCT blend sign in 12 (42.86%), respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of the spot sign for predicting hematoma expansion were 57.14%, 89.66%, 64.00%, and 86.67%, respectively. In contrast, the sensitivity, specificity, positive predictive value, and negative predictive value of the blend sign were 42.86%, 88.51%, 54.55%, and 82.80%, respectively. The area under the curve (AUC) of the spot sign was 0.734, which was higher than that of the blend sign (0.657). CONCLUSIONS Both the spot sign and the blend sign seemed to be good predictors for hematoma expansion, and the spot sign appeared to have better predictive accuracy.