Role of 'Spot Sign' on CT Angiography to Predict Hematoma Expansion in Spontaneous Intracerebral Hemorrhage

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.

The extravasation of contrast as a predictor of cerebral hemorrhagic contusion expansion, poor neurological outcome and mortality after traumatic brain injury: A systematic review and meta-analysis

Background

The active extravasation of contrast on CT angiography (CTA) in primary intracerebral hemorrhages (ICH) is recognized as a predictive factor for ICH expansion, unfavorable outcomes and mortality. However, few studies have been conducted on the setting of traumatic brain injury (TBI).

Purpose

To perform a literature systematic review and meta-analysis of the association of contrast extravasation on cerebral hemorrhagic contusion expansion, neurological outcomes and mortality.

Data sources

The PubMed, Cochrane Library, Medline, Scielo, VHL and IBECS databases up to September 21, 2019, were searched for eligible studies.

Study selection

A total of 505 individual titles and abstracts were identified and screened. A total of 36 were selected for full text analysis, out of which 4 fulfilled all inclusion and exclusion criteria.

Data analysis

All 4 studies yielded point estimates suggestive of higher risk for hematoma expansion with contrast extravasation and the summary RR was 5.75 (95%CI 2.74–10.47, p<0.001). Contrast extravasation was also associated with worse neurological outcomes (RR 3.25, 95%CI 2.24–4.73, p<0.001) and higher mortality (RR 2.77, 95%CI 1.03–7.47, p = 0.04).

Data synthesis

This study is a Systematic Review and Meta-Analysis revealed the extravasation of contrast is a useful imaging sign to predict hematoma expansion, worse neurological outcomes and higher mortality.

Limitations

Only four articles were selected.

Conclusions

The extravasation of contrast in the setting of TBI is a useful imaging sign to predict hematoma expansion, worse neurological outcomes and higher mortality.

Is four-dimensional CT angiography as effective as digital subtraction angiography in the detection of the underlying causes of intracerebral haemorrhage: a systematic review

PURPOSE

To determine whether the sensitivity and specificity of four-dimensional CTA (4D-CTA) are equivalent to digital subtraction angiography (DSA) in the detection of underlying vascular abnormalities in patients with intracerebral haemorrhage (ICH).

METHODS

A systematic review of studies comparing 4D-CTA with DSA in the detection of the underlying structural causes of ICH was performed on the literature published between 1998 and 2019.

RESULTS

We identified a total of 237 articles from PubMed, SCOPUS and Web of Science using the following Medical Subject Headings (MeSH) terms: primary intracerebral haemorrhage, 4D-CTA, DSA, cerebral haemorrhage, angiography, digital subtraction, arteriovenous malformations, 4D, CTA, dynamic-CTA and time-resolved CTA. Following the removal of duplicate publications and articles failing to meet our inclusion criteria, there were four articles potentially viable for analysis. Therefore, there were not sufficient studies to provide a statistically meaningful meta-analysis.

CONCLUSION

The review of current literature has demonstrated that there are few published studies comparing 4D-CTA with DSA in spontaneous ICH, with only four suitable studies identified for potential analysis. However, due to the restricted number of patients and high sensitivity and specificity of 3 studies (100%), performing a meta-analysis was not meaningful. Qualitative analysis of the data concluded that 4D-CTA has the diagnostic potential to replace invasive DSA in certain cases with vascular abnormalities. However, further research studies directly comparing 4D-CTA with DSA using larger prospective patient cohorts are required to strengthen the evidence base.

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.

Intracerebral haemorrhage: current approaches to acute management

Acute spontaneous intracerebral haemorrhage is a life-threatening illness of global importance, with a poor prognosis and few proven treatments. As a heterogeneous disease, certain clinical and imaging features help identify the cause, prognosis, and how to manage the disease. Survival and recovery from intracerebral haemorrhage are related to the site, mass effect, and intracranial pressure from the underlying haematoma, and by subsequent cerebral oedema from perihaematomal neurotoxicity or inflammation and complications from prolonged neurological dysfunction. A moderate level of evidence supports there being beneficial effects of active management goals with avoidance of early palliative care orders, well-coordinated specialist stroke unit care, targeted neurointensive and surgical interventions, early control of elevated blood pressure, and rapid reversal of abnormal coagulation.

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.

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.

Iodine concentration: a new, important characteristic of the spot sign that predicts haematoma expansion

OBJECTIVES

The computed tomography angiography (CTA) spot sign is a validated predictor of haematoma expansion (HE) in spontaneous intracerebral haemorrhage (SICH). We investigated whether defining the iodine concentration (IC) inside the spot sign and the haematoma on Gemstone spectral imaging (GSI) would improve its sensitivity and specificity for predicting HE.

METHODS

From 2014 to 2016, we prospectively enrolled 65 SICH patients who underwent single-phase spectral CTA within 6 h. Logistic regression was performed to assess the risk factors for HE. The predictive performance of individual spot sign characteristics was examined via receiver operating characteristic (ROC) analysis.

RESULTS

The spot sign was detected in 46.1% (30/65) of patients. ROC analysis indicated that IC inside the spot sign had the greatest area under the ROC curve for HE (0.858; 95% confidence interval, 0.727-0.989; p = 0.003). Multivariate analysis found that spot sign with higher IC (i.e. IC > 7.82 100 μg/ml) was an independent predictor of HE (odds ratio = 34.27; 95% confidence interval, 5.608-209.41; p < 0.001) with sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 0.81, 0.75, 0.90 and 0.60, respectively; while the spot sign showed sensitivity, specificity, PPV and NPV of 0.81, 0.79, 0.73 and 0.86. Logistic regression analysis indicated that the IC in haematomas was independently associated with HE (odds ratio = 1.525; 95% confidence interval, 1.041-2.235; p = 0.030).

CONCLUSIONS

ICs in haematoma and in spot sign were all independently associated with HE. IC analysis in spectral imaging may help to identify SICH patients for targeted haemostatic therapy.

KEY POINTS

• Iodine concentration in spot sign and haematoma can predict haematoma expansion • Spectral imaging could measure the IC inside the spot sign and haematoma • IC in spot sign improved the positive predictive value (PPV) cf. CTA.

Computed tomographic angiography in stroke and high-risk transient ischemic attack: Do not leave the emergency department without it!

Stroke is a major cause of morbidity and mortality worldwide, and effective treatment requires rapid diagnosis and recognition of relevant vascular lesions. In this review we will discuss the usefulness and versatility of computed tomography angiography in the setting of stroke, be it ischemic or hemorrhagic, minor or disabling. Furthermore, we also highlight how we use computed tomography angiography in decision making in transient ischemic attacks, acute disabling ischemic stroke, and hemorrhagic stroke.

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.

Predictive Value of CTA Spot Sign on Hematoma Expansion in Intracerebral Hemorrhage Patients

Hematoma expansion (HE) occurs in approximately one-third of patients with intracerebral hemorrhage and leads to high rates of mortality and morbidity. Currently, contrast extravasation within hematoma, termed the spot sign on computed tomography angiography (CTA), has been identified as a strong independent predictor of early hematoma expansion. Past studies indicate that the spot sign is a dynamic entity and is indicative of active hemorrhage. Furthermore, to enhance the spot sign's accuracy of predicting HE, spot parameters observed on CTA or dynamic CTA were used for its quantification. In addition, spot signs detected on multiphase CTA and dynamic CTA are shown to have higher sensitivity and specificity when compared with simple standardized spot sign detection in recent studies. Based on the spot sign, novel methods such as leakage sign and rate of contrast extravasation were explored to redefine HE prediction in combination with clinical characteristics and spot sign on CTA to assist clinical judgment. The spot sign is an accepted independent predictor of active hemorrhage and is used in both secondary intracerebral hemorrhage and the process of surgical assessment for hemorrhagic risk in patients with ischemic stroke. Spot sign predicts patients at high risk for hematoma expansion.

Imaging Evaluation of Acute Traumatic Brain Injury

Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide. Imaging plays an important role in the evaluation, diagnosis, and triage of patients with TBI. Recent studies suggest that it also helps predict patient outcomes. TBI consists of multiple pathoanatomic entities. This article reviews the current state of TBI imaging including its indications, benefits and limitations of the modalities, imaging protocols, and imaging findings for each of these pathoanatomic entities. Also briefly surveyed are advanced imaging techniques, which include several promising areas of TBI research.

Predicting Intracerebral Hemorrhage Growth With the Spot Sign: The Effect of Onset-to-Scan Time

BACKGROUND AND PURPOSE

Hematoma expansion after acute intracerebral hemorrhage is common and is associated with early deterioration and poor clinical outcome. The computed tomographic angiography (CTA) spot sign is a promising predictor of expansion; however, frequency and predictive values are variable across studies, possibly because of differences in onset-to-CTA time. We performed a patient-level meta-analysis to define the relationship between onset-to-CTA time and frequency and predictive ability of the spot sign.

METHODS

We completed a systematic review for studies of CTA spot sign and hematoma expansion. We subsequently pooled patient-level data on the frequency and predictive values for significant hematoma expansion according to 5 predefined categorized onset-to-CTA times. We calculated spot-sign frequency both as raw and frequency-adjusted rates.

RESULTS

Among 2051 studies identified, 12 met our inclusion criteria. Baseline hematoma volume, spot-sign status, and time-to-CTA were available for 1176 patients, and 1039 patients had follow-up computed tomographies for hematoma expansion analysis. The overall spot sign frequency was 26%, decreasing from 39% within 2 hours of onset to 13% beyond 8 hours (P<0.001). There was a significant decrease in hematoma expansion in spot-positive patients as onset-to-CTA time increased (P=0.004), with positive predictive values decreasing from 53% to 33%.

CONCLUSIONS

The frequency of the CTA spot sign is inversely related to intracerebral hemorrhage onset-to-CTA time. Furthermore, the positive predictive value of the spot sign for significant hematoma expansion decreases as time-to-CTA increases. Our results offer more precise risk stratification for patients with acute intracerebral hemorrhage and will help refine clinical prediction rules for intracerebral hemorrhage expansion.

Intracerebral Hematoma Morphologic Appearance on Noncontrast Computed Tomography Predicts Significant Hematoma Expansion

Background and Purpose—

Hematoma expansion in intracerebral hemorrhage is associated with higher morbidity and mortality. The computed tomography (CT) angiographic spot sign is highly predictive of expansion, but other morphological features of intracerebral hemorrhage such as fluid levels, density heterogeneity, and margin irregularity may also predict expansion, particularly in centres where CT angiography is not readily available.

Methods—

Baseline noncontrast CT scans from patients enrolled in the Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT (PREDICT) study were assessed for the presence of fluid levels and degree of density heterogeneity and margin irregularity using previously validated scales. Presence and grade of these metrics were correlated with the presence of hematoma expansion as defined by the PREDICT study on 24-hour follow-up scan.

Results—

Three hundred eleven patients were included in the analysis. The presence of fluid levels and increasing heterogeneity and irregularity were associated with 24-hour hematoma expansion ( P =0.021, 0.003 and 0.049, respectively) as well as increases in absolute hematoma size. Fluid levels had the highest positive predictive value (50%; 28%–71%), whereas margin irregularity had the highest negative predictive value (78%; 71%–85). Noncontrast metrics had comparable predictive values as spot sign for expansion when controlled for vitamin K, antiplatelet use, and baseline National Institutes of Health Stroke Scale, although in a combined area under the receiver-operating characteristic curve model, spot sign remained the most predictive.

Conclusions—

Fluid levels, density heterogeneity, and margin irregularity on noncontrast CT are associated with hematoma expansion at 24 hours. These markers may assist in prediction of outcomes in scenarios where CT angiography is not readily available and may be of future help in refining the predictive value of the CT angiography spot sign.

Contusion Contrast Extravasation Depicted on Multidetector Computed Tomography Angiography Predicts Growth and Mortality in Traumatic Brain Contusion

Traumatic brain injury (TBI) is the main cause of death in trauma victims and causes high rates of disability and neurological sequelae. Approximately 38-65% of traumatic brain contusions (TBC) demonstrate hemorrhagic expansion on serial computed tomography (CT) scans. Thus far, however, no single variable can accurately predict the hemorrhage expansion of a TBC. Our purpose was to evaluate contrast extravasation (CE) as a predictor of expansion, mortality, and poor outcome in TBC in a Brazilian cohort. After Institutional Review Board approval, we used multidetector CT angiography (MDCTA) to study 121 consecutive patients (106 men, 87.6%) with ages varying from 10 to 85 years. Informed consent was obtained from all subjects. The clinical and imaging findings were correlated with the findings on the initial MDCTA using either the Fisher exact test or Student t test and a multivariate logistic regression model. Of the persons who presented CE in TBC, 21.8% died (in-hospital mortality), whereas in the absence of this sign, the mortality rate was 7.6% (p = 0.014). In addition, expansion of the hemorrhagic component of the TBC was detected in 61.1% of the CE-positive patients, whereas expansion was only observed in 10% of the CE-negative patients (p < 0.001). Poor outcome was observed in 24.2% of the patients in the CE-negative group, but in the presence of CE, 72.7% evolved with poor outcome (p < 0.001). The CE was a strong independent predictor of expansion, poor outcome, and increased risk of in-hospital mortality in our series of patients with TBC.

Management and Outcome of Spontaneous Cerebellar Hemorrhage

Objective

Spontaneous cerebellar hemorrhage (SCH) is less common than supratentorial intracerebral hemorrhage. This study investigated the treatment of SCH and the relation between its clinical and radiological manifestation and outcome.

Materials and Methods

We presented a SCH management protocol in our institute and analyzed the clinical and radiological findings in 41 SCH patients. The outcomes of each method (surgery and conservative treatment) were compared among patients with initial Glasgow Coma Scale (GCS) score of 9-13 and hematoma volume greater than 10 mL.

Results

Two (4.9%), 16 (39%), and 23 (56.1%) patients had an initial GCS score of 3-8, with 3-8, 9-13, and 14-15, respectively. Initial GCS score showed significant correlation with Glasgow Outcome Scale (GOS) score (p = 0.005). The mean largest hematoma diameter was 3.2 ± 1.5 cm, and the mean volume was 11.0 ± 11.5 mL. Both of them showed significant inverse correlation with GOS score (p < 0.001). Among patients with an initial GCS score of 9-13 and hematoma volumes greater than 10 mL, 3 (50%) had good outcome and 3 (50%) had poor outcome in the surgical, and all of those in the conservative treatment group had poor outcomes. The outcome distribution differed significantly in the surgical and conservative groups (p = 0.030).

Conclusion

Initial GCS score and largest hematoma diameter and volume on brain computed tomography are important determinants of outcome in SCH patients. The surgery group showed better outcome than the conservative treatment group among those with an intermediate neurological status and large hematomas.

Dual-Energy CT: What the Neuroradiologist Should Know

Because of the different attenuations of tissues at different energy levels, dual-energy CT offers tissue differentiation and characterization, reduction of artifacts, and remodeling of contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR), hereby creating new opportunities and insights in CT imaging. The applications for dual-energy imaging in neuroradiology are various and still expanding. Automated bone removal is used in CT angiography and CT venography of the intracranial vessels. Monoenergetic reconstructions can be used in patients with or without metal implants in the brain and spine to reduce artifacts, improve CNR and SNR, or to improve iodine conspicuity. Differentiation of iodine and hemorrhage is used in high-density lesions, after intra-arterial recanalization in stroke patients or after administration of contrast media. Detection of underlying (vascular and non-vascular) pathology and spot sign can be used in patients presenting with (acute) intracranial hemorrhage.

The spot sign predicts hematoma expansion, outcome, and mortality in patients with primary intracerebral hemorrhage

Objective

The purpose of this study was to retrospectively review cases of intracerebral hemorrhage (ICH) medically treated at our institution to determine if the CT angiography (CTA) 'spot sign' predicts in-hospital mortality and clinical outcome at 3 months in patients with spontaneous ICH.

Methods

We conducted a retrospective review of all consecutive patients who were admitted to the department of neurosurgery. Clinical data of patients with ICH were collected by 2 neurosurgeons blinded to the radiological data and at the 90-day follow-up.

Results

Multivariate logistic regression analysis identified predictors of poor outcome; we found that hematoma location, spot sign, and intraventricular hemorrhage were independent predictors of poor outcome. In-hospital mortality was 57.4% (35 of 61) in the CTA spot-sign positive group versus 7.9% (10 of 126) in the CTA spot-sign negative group. In multivariate logistic analysis, we found that presence of spot sign and presence of volume expansion were independent predictors for the in-hospital mortality of ICH.

Conclusion

The spot sign is a strong independent predictor of hematoma expansion, mortality, and poor clinical outcome in primary ICH. In this study, we emphasized the importance of hematoma expansion as a therapeutic target in both clinical practice and research.

Association Factors for CT Angiography Spot Sign and Hematoma Growth in Korean Patients with Acute Spontaneous Intracerebral Hemorrhage : A Single-Center Cohort Study

Objective

This study was conducted to clarify the association factors and clinical significance of the CT angiography (CTA) spot sign and hematoma growth in Korean patients with acute intracerebral hemorrhage (ICH).

Methods

We retrospectively collected the data of 287 consecutive patients presenting with acute ICH who arrived within 12 hours of ictus. Baseline clinical and radiological characteristics as well as the mortality rate within one month were assessed. A binary logistic regression was conducted to obtain association factors for the CTA spot sign and hematoma growth.

Results

We identified a CTA spot sign in 40 patients (13.9%) and hematoma growth in 78 patients (27.2%). An elapsed time to CT scan of less than 3 hours (OR, 5.14; 95% CI, 1.76-15.02; p=0.003) was associated with the spot sign. A CTA spot sign (OR, 5.70; 95% CI, 2.70-12.01; p<0.001), elevated alanine transaminase (GPT) level >40 IU (OR, 2.01; 95% CI, 1.01-4.01; p=0.047), and an international normalized ratio ≥1.8 or warfarin medication (OR, 5.64; 95% CI, 1.29-24.57; p=0.021) were independent predictors for hematoma growth. Antiplatelet agent medication (OR, 4.92; 95% CI, 1.31-18.50; p=0.019) was significantly associated with hematoma growth within 6 hours of ictus.

Conclusion

As previous other populations, CTA spot sign was a strong predictor for hematoma growth especially in hyper-acute stage of ICH in Korea. Antithrombotics medication might also be associated with hyper-acute hematoma growth. In our population, elevated GPT was newly identified as a predictor for hematoma growth and its effect for hematoma growth is necessary to be confirmed through a further research.

Which emphasizing factors are most predictive of hematoma expansion in spot sign positive intracerebral hemorrhage?

Objective

The spot sign is related with the risk of hematoma expansion in spontaneous intracerebral hemorrhage (ICH). However, not all spot sign positive patients undergo hematoma expansion. Thus, the present study investigates the specific factors enhancing the spot sign positivity in predicting hematoma expansion.

Methods

We retrospectively studied 316 consecutive patients who presented between March 2009 to March 2011 with primary ICH and whose initial computed tomography brain angiography (CTA) was performed at our Emergency Department. Of these patients, 47 primary ICH patients presented spot signs in their CTA. We classified these 47 patients into two groups based on the presence of hematoma expansion then analyzed them with the following factors : gender, age, initial systolic blood pressure, history of anti-platelet therapy, volume and location of hematoma, time interval from symptom onset to initial CTA, spot sign number, axial dimension, and Hounsfield Unit (HU) of spot signs.

Results

Of the 47 spot sign positive patients, hematoma expansion occurred in 26 patients (55.3%) while the remaining 21 (44.7%) showed no expansion. The time intervals from symptom onset to initial CTA were 2.42±1.24 hours and 3.69±2.57 hours for expansion and no expansion, respectively (p=0.031). The HU of spot signs were 192.12±45.97 and 151.10±25.14 for expansion and no expansion, respectively (p=0.001).

Conclusions

The conditions of shorter time from symptom onset to initial CTA and higher HU of spot signs are the emphasizing factors for predicting hematoma expansion in spot sign positive patients.

Accuracy of the spot sign on computed tomography angiography as a predictor of haematoma enlargement after acute spontaneous intracerebral haemorrhage: a systematic review

BACKGROUND

A common early complication of intracerebral haemorrhage (ICH) is haematoma enlargement (HE), a strong independent predictor of a poor outcome. Therapeutic options to limit haematoma progression are currently scarce. Haemostatic therapy may be effective in patients with ICH, but it carries the risk of thromboembolic events in unselected patients. Accurate patient selection would, therefore, be of key importance for delivering potentially successful therapeutic strategies. Currently, there is no gold standard to accurately predict HE. The presence of contrast extravasation within the haematoma on computed tomography angiography (CTA), the 'spot sign', has been reported in several studies and seems a particularly promising marker but lacks a standardised evaluation so far.

SUMMARY

We conducted a systematic review of published data to address the research question: In adults with acute spontaneous ICH, how accurately does the spot sign predict HE on follow-up imaging and thus poor functional outcome or mortality? We searched PubMed and Embase databases (from 1980 to May 2012), using a highly sensitive search strategy and including all studies involving adult patients with spontaneous ICH evaluated with CTA and follow-up CT scans, reporting any measure of clinical outcome, and reporting or allowing calculation of accuracy measures of the spot sign in predicting HE and clinical outcome. Baseline characteristics, accuracy measures and effect measures, as well as bias assessment, were reported according to PRISMA recommendations. The quality of the studies was appraised using an adapted version of the REMARK reporting recommendations. From 259 potentially relevant studies, we finally selected 6 studies (1 of them was a multicentre cohort study) covering a total of 709 patients. Studies varied substantially in terms of size, methodological quality, definitions of terms, outcomes selected and results. In particular, definition of the spot sign was not consistent in all studies. Furthermore, the only outcome measure consistently available was HE, while definitions and analyses of clinical outcomes seemed not adequate. Lastly, the choice of candidate variables for univariate and multivariate analyses did not include all determinants of HE and poor functional outcome. High heterogeneity was demonstrated (I(2): 94% for HE) with substantial potential of bias.

KEY MESSAGES

Studies of the spot sign are diverse and therefore complex to interpret. Our research question could not be answered due to heterogeneity and potential of bias in the selected studies. Further appropriately powered studies using standardised definitions and taking all predictors of HE and poor clinical outcome into account are required for a proper clinical implementation.

Dual-energy CT for detection of contrast enhancement or leakage within high-density haematomas in patients with intracranial haemorrhage

INTRODUCTION

Our study aimed to elucidate the diagnostic performance of dual-energy CT (DECT) in the detection of contrast enhancement in intracranial haematomas (ICrH) with early phase dual-energy computed tomography angiography (CTA) and compare the results with those obtained by delayed CT enhancement.

METHODS

Thirty-six patients with ICrH were retrospectively included in this study. All patients had undergone single-energy non-contrast CT and contrast-enhanced dual-source DECT. DECT images were post-processed with commercial software, followed by obtaining iodine images and virtual non-contrast images and generating combined images that created the impression of 120-kVp images. Two neuroradiologists, blinded to the patients' data, reviewed two reading sessions: session A (non-contrast CT and combined CT) and session B (non-contrast CT, combined CT, and iodine images) for detection of contrast enhancement in the haematomas.

RESULTS

Contrast leakage or enhancement was detected in 23 (57.5 %) out of 40 haemorrhagic lesions in 36 patients on delayed CT. Three enhanced lesions were depicted only in the DECT iodine images. The sensitivity, specificity, positive predictive value, and negative predictive value of session A were 82.6, 94.1, 95.0, and 80.0 %, respectively, and those of session B were 95.7, 94.1, 95.7, and 94.1 %, respectively.

CONCLUSION

DECT emphasised the iodine enhancement and facilitated the detection of contrast enhancement or leakage.

Mortality and real cause of death from the nonlesional intracerebral hemorrhage

Objective

The case fatality rate of nonlesional intracerebral hemorrhage (n-ICH) was high and not changed. Knowing the causes is important to their prevention; however, the reasons have not been studied. The aims of this study were to determine the cause of death, to improve the clinical outcomes.

Methods

We retrospectively analyzed consecutive cases of nonlesional intracerebral hemorrhage in a prospective stroke registry from January 2010 to December 2010.

Results

Among 174 patients (61.83±13.36, 28-90 years), 29 patients (16.7%) died during hospitalization. Most common cause of death was initial neurological damage (41.4%, 12/29). Seventeen patients who survived the initial damage may then develop various potentially fatal complications. Except for death due to the initial neurological sequelae, death associated with immobilization (such as pneumonia or thromboembolic complication) was the most common in eight cases (8/17, 47.1%). However, death due to early rebleeding was not common and occurred in only 2 cases (2/17, 11.8%). Age, initial Glasgow Coma Scale, and diabetes mellitus were statistically significant factors influencing mortality (p<0.05).

Conclusion

Mortality of n-ICH is still high. Initial neurological damage is the most important factor; however, non-neurological medical complications are a large part of case fatality. Most cases of death of patients who survived from the first bleeding were due to complications of immobilization. These findings have implications for clinical practice and planning of clinical trials. In addition, future conduct of a randomized study will be necessary in order to evaluate the benefits of early mobilization for prevention of immobilization related complications.

Computed Tomography Angiography in the Assessment of Patients With Stroke/TIA

Rapid advance in medical technology has resulted in the availability of numerous tests and treatment strategies in the management of acute stroke. The increasingly evidence-based context of clinical medicine necessitates that clinicians use only appropriate tools to facilitate the diagnostic process and patient management. In this review, we seek to explore the use of computed tomography angiography (CTA) in the diagnosis and management of patients presenting with acute stroke (ischemic and hemorrhagic) or transient ischemic attack (TIA). We present evidence in favor of the use of CTA, highlight the disadvantages of this imaging modality, and present a heuristic model based on our experience at utilizing CTA for decision making in acute stroke and TIAs.

Contrast extravasation on CT angiography predicts hematoma expansion and mortality in acute traumatic subdural hemorrhage

BACKGROUND AND PURPOSE

The presence of active contrast extravasation at CTA predicts hematoma expansion and in-hospital mortality in patients with nontraumatic intracerebral hemorrhage. This study aims to determine the frequency and predictive value of the contrast extravasation in patients with aSDH.

MATERIALS AND METHODS

We retrospectively reviewed 157 consecutive patients who presented to our emergency department over a 9-year period with aSDH and underwent CTA at admission and a follow-up NCCT within 48 hours. Two experienced readers, blinded to clinical data, reviewed the CTAs to assess for the presence of contrast extravasation. Medical records were reviewed for baseline clinical characteristics and in-hospital mortality. aSDH maximum width in the axial plane was measured on both baseline and follow-up NCCTs, with hematoma expansion defined as >20% increase from baseline.

RESULTS

Active contrast extravasation was identified in 30 of 199 discrete aSDHs (15.1%), with excellent interobserver agreement (κ = 0.80; 95% CI, 0.7-0.9). The presence of contrast extravasation indicated a significantly increased risk of hematoma expansion (odds ratio, 4.5; 95% CI, 2.0-10.1; P = .0001) and in-hospital mortality (odds ratio, 7.6; 95% CI, 2.6-22.3; P = 0.0004). In a multivariate analysis controlled for standard risk factors, the presence of contrast extravasation was an independent predictor of aSDH expansion (P = .001) and in-hospital mortality (P = .0003).

CONCLUSIONS

Contrast extravasation stratifies patients with aSDH into those at high risk and those at low risk of hematoma expansion and in-hospital mortality. This distinction could affect patient treatment, clinical trial selection, and possible surgical intervention.

Traumatic intracranial hematomas: prognostic value of contrast extravasation

BACKGROUND AND PURPOSE

Contrast extravasation within spontaneous intracranial hemorrhage is a well-described predictor of hematoma growth, poor clinical outcome, and mortality. The purpose of this study was to assess the prognostic value of contrast extravasation in acute traumatic intracranial hematomas.

MATERIALS AND METHODS

In our institution, CTA (including PCCT) is the primary screening technique for cervical vascular injuries. Sixty consecutive patients with at least 1 acute intracranial hematoma (ICH, subdural hematoma, and/or epidural hematoma) meeting predefined size criteria, with CTA/PCCT performed within 24 hours of admission and follow-up CT within 72 hours of admission, were retrospectively evaluated for CE by 2 observers. The predictive value of CE for a composite outcome (hematoma expansion, need for hematoma evacuation, in-hospital mortality) was evaluated on a per-patient basis. Interobserver agreement for CE and the association between baseline variables and outcome were also examined. Different patterns of extravasation were evaluated on a per-lesion basis, with outcomes including hematoma expansion and evacuation.

RESULTS

CE was present in 30 (50%) patients with almost perfect interobserver agreement (κ=0.87; 95% CI, 0.74-0.99). The per-patient multivariate analysis showed independent association of midline shift (P=.020), Glasgow Coma Scale score≤8 (P=.024), and CE (P=.017), with poor outcome and demonstrated a trend toward poor outcome prediction for age 65 years or older (P=.050). In the per-lesion analysis, only extravasation identified on CTA (active and contained extravasation) was associated with hematoma expansion and evacuation.

CONCLUSIONS

Contrast extravasation within intracranial hematomas predicts poor in-hospital outcome in the setting of acute traumatic intracranial injuries.

Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign (PREDICT): a prospective observational study

BACKGROUND

In patients with intracerebral haemorrhage (ICH), early haemorrhage expansion affects clinical outcome. Haemostatic treatment reduces haematoma expansion, but fails to improve clinical outcomes in many patients. Proper selection of patients at high risk for haematoma expansion seems crucial to improve outcomes. In this study, we aimed to prospectively validate the CT-angiography (CTA) spot sign for prediction of haematoma expansion.

METHODS

PREDICT (predicting haematoma growth and outcome in intracerebral haemorrhage using contrast bolus CT) was a multicentre prospective observational cohort study. We recruited patients aged 18 years or older, with ICH smaller than 100 mL, and presenting at less than 6 h from symptom onset. Using two independent core laboratories, one neuroradiologist determined CTA spot-sign status, whereas another neurologist masked for clinical outcomes and imaging measured haematoma volumes by computerised planimetry. The primary outcome was haematoma expansion defined as absolute growth greater than 6 mL or a relative growth of more than 33% from initial CT to follow-up CT. We reported data using standard descriptive statistics stratified by the CTA spot sign. Mortality was assessed with Kaplan-Meier survival analysis.

FINDINGS

We enrolled 268 patients. Median time from symptom onset to baseline CT was 135 min (range 22-470), and time from onset to CTA was 159 min (32-475). 81 (30%) patients were spot-sign positive. The primary analysis included 228 patients, who had a follow-up CT before surgery or death. Median baseline ICH volume was 19·9 mL (1·5-80·9) in spot-sign-positive patients versus 10·0 mL (0·1-102·7) in spot-sign negative patients (p<0·001). Median ICH expansion was 8·6 mL (-9·3 to 121·7) for spot-sign positive patients and 0·4 mL (-11·7 to 98·3) for spot-negative patients (p<0·001). In those with haematoma expansion, the positive predictive value for the spot sign was61% (95% CI 47–73) for the positive predictive value and 78% (71–84) for the negative predictive value, with 51% (39–63) sensitivity and 85% (78–90) specificity[corrected]. Median 3-month modified Rankin Scale (mRS) was 5 in CTA spot-sign-positive patients, and 3 in spot-sign-negative patients (p<0·001). Mortality at 3 months was 43·4% (23 of 53) in CTA spot-sign positive versus 19·6% (31 of 158) in CTA spot-sign-negative patients (HR 2·4, 95% CI 1·4-4·0, p=0·002).

INTERPRETATION

These findings confirm previous single-centre studies showing that the CTA spot sign is a predictor of haematoma expansion. The spot sign is recommended as an entry criterion for future trials of haemostatic therapy in patients with acute ICH.

FUNDING

Canadian Stroke Consortium and NovoNordisk Canada.