Computed Tomography Angiography Spot Research Articles

Association Between Hypodensities Detected by Computed Tomography and Hematoma Expansion in Patients With Intracerebral Hemorrhage.

Hematoma expansion is a potentially modifiable predictor of poor outcome following an acute intracerebral hemorrhage (ICH). The ability to identify patients with ICH who are likeliest to experience hematoma expansion and therefore likeliest to benefit from expansion-targeted treatments remains an unmet need. Hypodensities within an ICH detected by noncontrast computed tomography (NCCT) have been suggested as a predictor of hematoma expansion. To determine whether hypodense regions, irrespective of their specific patterns, are associated with hematoma expansion in patients with ICH. We analyzed a large cohort of 784 patients with ICH (the development cohort; 55.6% female), examined NCCT findings for any hypodensity, and replicated our findings on a different cohort of patients (the replication cohort; 52.7% female). Baseline and follow-up NCCT data from consecutive patients with ICH presenting to a tertiary care hospital between 1994 and 2015 were retrospectively analyzed. Data analyses were performed between December 2015 and January 2016. Hypodensities were analyzed by 2 independent blinded raters. The association between hypodensities and hematoma expansion (>6 cm3 or 33% of baseline volume) was determined by multivariable logistic regression after controlling for other variables associated with hematoma expansion in univariate analyses with P ≤ .10. A total of 1029 patients were included in the analysis. In the development and replication cohorts, 222 of 784 patients (28.3%) and 99 of 245 patients (40.4%; 321 of 1029 patients [31.2%]), respectively, had NCCT scans that demonstrated hypodensities at baseline (κ = 0.87 for interrater reliability). In univariate analyses, hypodensities were associated with hematoma expansion (86 of 163 patients with hematoma expansion had hypodensities [52.8%], whereas 136 of 621 patients without hematoma expansion had hypodensities [21.9%]; P < .001). The association between hypodensities and hematoma expansion remained significant (odds ratio, 3.42 [95% CI, 2.21-5.31]; P < .001) in a multivariable model; other independent predictors of hematoma expansion were a CT angiography spot sign, a shorter time to CT, warfarin use, and older age. The independent predictive value of hypodensities was again demonstrated in the replication cohort (odds ratio, 4.37 [95% CI, 2.05-9.62]; P < .001). Hypodensities within an acute ICH detected on an NCCT scan may predict hematoma expansion, independent of other clinical and imaging predictors. This novel marker may help clarify the mechanism of hematoma expansion and serve as a useful addition to clinical algorithms for determining the risk of and treatment stratification for hematoma expansion.

Ultraearly hematoma growth in active intracerebral hemorrhage.

To determine the association of ultraearly hematoma growth (uHG) with the CT angiography (CTA) spot sign, hematoma expansion, and clinical outcomes in patients with acute intracerebral hemorrhage (ICH). We analyzed data from 231 patients enrolled in the multicenter Predicting Haematoma Growth and Outcome in Intracerebral Haemorrhage Using Contrast Bolus CT study. uHG was defined as baseline ICH volume/onset-to-CT time (mL/h). The spot sign was used as marker of active hemorrhage. Outcome parameters included significant hematoma expansion (>33% or >6 mL, primary outcome), rate of hematoma expansion, early neurologic deterioration, 90-day mortality, and poor outcome. uHG was higher in spot sign patients (p < 0.001) and in patients scanned earlier (p < 0.001). Both uHG >4.7 mL/h (p = 0.002) and the CTA spot sign (p = 0.030) showed effects on rate of hematoma expansion but not its interaction (2-way analysis of variance, p = 0.477). uHG >4.7 mL/h improved the sensitivity of the spot sign in the prediction of significant hematoma expansion (73.9% vs 46.4%), early neurologic deterioration (67.6% vs 35.3%), 90-day mortality (81.6% vs 44.9%), and poor outcome (72.8% vs 29.8%), respectively. uHG was independently related to significant hematoma expansion (odds ratio 1.06, 95% confidence interval 1.03-1.10) and clinical outcomes. uHG is a useful predictor of hematoma expansion and poor clinical outcomes in patients with acute ICH. The combination of high uHG and the spot sign is associated with a higher rate of hematoma expansion, highlighting the need for very fast treatment in ICH patients.

Comment: The elusive search for markers of hematoma expansion.

Hematoma expansion occurs in up to 40% of intracerebral hemorrhage (ICH) patients within 6 hours from the onset. Stopping the expansion is one aim of randomized clinical studies,1 and an important clinical imperative. CT angiography (CTA) spot sign is a known marker, found in about 30% of patients. Ultraearly hematoma growth (uHG) (expressed as the ratio between hematoma volume [mL] and time [h] from onset to imaging acquisition) is also a useful marker of hematoma expansion.

Abstract WP365: Role of Enhanced CT Findings in Endoscopic Surgery for Intracerebral Hematoma

Objective: In our institute, endoscopic aspiration of hematoma is often performed for acute treatment of intracerebral hematoma (ICH). In some cases, hemostasis is technically difficult to perform during endoscopy, and post-operative hemorrhage may occur. We examined the association between perioperative complications associated with endoscopic surgery for acute ICH, and radiological findings on enhanced computed tomography (CT). Methods: Subjects were 471 patients diagnosed with hypertensive ICH who had been admitted and treated in our institute within 72 hours from onset, between 2012 and 2015. Enhanced CT imaging was performed at admission, and radiological enhancement signs (RES) were defined as CT angiography spot signs in the arterial phase, or contrast extravasation in the parallel phase. RES-positive subjects were grouped and compared with an equal number of RES-negative subjects, and the association between perioperative complications and RES was analyzed. Results: The RES-positive group included 39 subjects; endoscopic surgery was performed in 16 of the 39 subjects. Postoperative hemorrhage occurred in 6 of the 16 subjects. No hemorrhagic complications were found in the RES-negative group. Follow-up CT after 24 hours showed hematoma expansion in 20 of 26 subjects in the RES-positive group and in only 1 of the 39 subjects of the RES-negative group. Statistical analyses showed that the RES-positive group had a significantly shorter duration between the onset of ICH and CT scan and significantly larger hematoma volume, compared with the RES-negative group. Multivariate analysis identified the presence of RES as a significant risk factor of postoperative hemorrhage or hematoma expansion on follow-up CT. Conclusion: CT angiography spot signs or contrast extravasation positive signs were observed with a shorter duration between ICH onset and CT scan, and larger hematomas. These signs may be an important predictive factor for hematoma expansion, as well as a significant risk factor of postoperative hemorrhage after endoscopic surgery for ICH.

Abstract TP372: CT Angiography Spot Sign, Hematoma Expansion and Outcome in Primary Pontine Intracerebral Hemorrhage

Background and Purpose: The computed tomography angiography (CTA) spot sign is a validated predictor of hematoma expansion and poor outcome in supratentorial intracerebral hemorrhage (ICH), but patients with brainstem ICH have typically been excluded from analyses. We investigated the frequency of spot sign and its relationship with hematoma expansion and outcome in patients with primary pontine hemorrhage (PPH). Methods: We performed a retrospective analysis of a prospectively collected cohort of consecutive PPH patients who underwent CTA. CTA first pass readings for spot sign presence were analyzed by two trained readers. Baseline and follow-up hematoma volumes on noncontrast CT scans were assessed by semi-automated computer-assisted volumetric analysis. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive and negative likelihood ratio and accuracy of spot sign in predicting in-hospital mortality were calculated. Results: 49 subjects met the inclusion criteria of whom 11 (22.4%) showed a spot sign. In-hospital mortality was higher in spot sign positive versus negative subjects (90.9% vs 47.4%, p=0.020). Spot sign showed excellent specificity (95%) and PPV (91%) in predicting in-hospital mortality. Absolute hematoma growth, defined as parenchymal and intraventricular hematoma expansion of any amount, was significantly higher in spot sign positive versus negative subjects (3.76 ± 8.55 vs 13.72 ± 20.93 mL, p=0.045). Conclusions: As with supratentorial ICH, spot sign presence is a common finding and is associated with higher risk of hematoma expansion and mortality in PPH.

CT Angiography Spot Sign, Hematoma Expansion, and Outcome in Primary Pontine Intracerebral Hemorrhage.

The computed tomography angiography (CTA) spot sign is a validated predictor of hematoma expansion and poor outcome in supratentorial intracerebral hemorrhage (ICH), but patients with brainstem ICH have typically been excluded from the analyses. We investigated the frequency of spot sign and its relationship with hematoma expansion and outcome in patients with primary pontine hemorrhage (PPH). We performed a retrospective analysis of PPH cases obtained from a prospectively collected cohort of consecutive ICH patients who underwent CTA. CTA first-pass readings for spot sign presence were analyzed by two trained readers. Baseline and follow-up hematoma volumes on non-contrast CT scans were assessed by semi-automated computer-assisted volumetric analysis. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive and negative likelihood ratio, and accuracy of spot sign for prediction of in-hospital mortality were calculated. 49 subjects met the inclusion criteria of whom 11 (22.4%) showed a spot sign. In-hospital mortality was higher in spot sign-positive versus spot sign-negative subjects (90.9 vs 47.4%, p=0.020). Spot sign showed excellent specificity (95%) and PPV (91%) in predicting in-hospital mortality. Absolute hematoma growth, defined as parenchymal and intraventricular hematoma expansion of any amount, was significantly higher in spot sign-positive versus spot sign-negative subjects (13.72±20.93 vs 3.76±8.55mL, p=0.045). As with supratentorial ICH, the CTA spot sign is a common finding and is associated with higher risk of hematoma expansion and mortality in PPH. This marker may assist clinicians in prognostic stratification.

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

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. 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. 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. 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.

Abstract 93: Do Intracerebral Hemorrhage “Non-Expanders” Actually Expand into the Ventricular Space?

Background: The CT-angiography spot sign as a predictor of hematoma expansion (HE) is limited by its modest sensitivity and PPV. Spot sign studies restrict HE definitions to the parenchymal component of ICH and do not consistently evaluate intraventricular hemorrhage (IVH) expansion. Decompression of ICH into the ventricular space can lead to underestimation of HE and overestimation of false-positive spot signs. We hypothesized that a proportion of ICH “non-expanders” expand into the ventricular space and including IVH expansion in HE definitions will improve the predictive performance of the spot sign. Our objectives were: 1) determine the proportion of ICH “non-expanders” who have IVH expansion, 2) determine the proportion of “false-positive” spot signs that have IVH expansion, 3) compare the known predictive performance of the spot sign to its performance when using an HE definition incorporating IVH expansion, and 4) explore the predictors of IVH expansion. Methods: We analyzed patients from the multicenter PREDICT ICH spot sign study. We defined HE as ≥6mL or ≥33% ICH expansion or &gt;2ml IVH expansion, and compared the performance of this new definition with the conventional 6mL/33% parenchymal definition using ROC analysis. We used regression analysis to determine the predictors of IVH expansion. Results: Of 315 patients with complete imaging, 215 did not meet the 6mL/33% expansion definition ("non-expanders"). Only 14/215 (6.5%) of “non-expanders” had ≥2mL IVH expansion. Of the “false positive” spot signs, 4/39 (10.3%) had &gt;2mL ventricular expansion. The AUC for spot sign to predict significant ICH expansion was 0.65 [95% CI 0.58-0.72], which was no different then when IVH expansion was added to the HE definition: AUC 0.64 [95% CI 0.58-0.71]. Predictors for IVH expansion included IVH at baseline (aOR 2.5, p=0.013), elevated INR (aOR 2.5, p=0.011), and spot sign (aOR 5.9, p&lt;0.001). Conclusions: IVH expansion occurs in a small minority of “non-expanders”, and only 10% of “false positive” post signs actually expended in the ventricular space. Furthermore, revising HE definitions to include IVH expansion did not alter the predictive performance of the spot sign.

CT angiography spot sign in intracerebral hemorrhage predicts active bleeding during surgery.

To determine whether the CT angiography (CTA) spot sign marks bleeding complications during and after surgery for spontaneous intracerebral hemorrhage (ICH). In a 2-center study of consecutive spontaneous ICH patients who underwent CTA followed by surgical hematoma evacuation, 2 experienced readers (blinded to clinical and surgical data) reviewed CTAs for spot sign presence. Blinded raters assessed active intraoperative and postoperative bleeding. The association between spot sign and active intraoperative bleeding, postoperative rebleeding, and residual ICH volumes was evaluated using univariable and multivariable logistic regression. A total of 95 patients met inclusion criteria: 44 lobar, 17 deep, 33 cerebellar, and 1 brainstem ICH; ≥1 spot sign was identified in 32 patients (34%). The spot sign was the only independent marker of active bleeding during surgery (odds ratio [OR] 3.4; 95% confidence interval [CI] 1.3-9.0). Spot sign (OR 4.1; 95% CI 1.1-17), female sex (OR 6.9; 95% CI 1.7-37), and antiplatelet use (OR 4.6; 95% CI 1.2-21) were predictive of postoperative rebleeding. Larger residual hematomas and postoperative rebleeding were associated with higher discharge case fatality (OR 3.4; 95% CI 1.1-11) and a trend toward increased case fatality at 3 months (OR 2.9; 95% CI 0.9-8.8). The CTA spot sign is associated with more intraoperative bleeding, more postoperative rebleeding, and larger residual ICH volumes in patients undergoing hematoma evacuation for spontaneous ICH. The spot sign may therefore be useful to select patients for future surgical trials.

Predictors of the CT Angiography Spot Sign in Deep and Lobar Intracerebral Hemorrhage (P5.143)

Predictors of the CT Angiography Spot Sign in Deep and Lobar Intracerebral Hemorrhage (P5.143)

Abstract W P257: Predictors of the CT Angiography Spot Sign in Deep and Lobar Intracerebral Hemorrhage

Objectives: Intracerebral hemorrhage (ICH) patients with CT angiography (CTA) spot sign are at increased risk of hematoma expansion and poor outcome. Since ICH is often the acute manifestation of a chronic cerebral vasculopathy, we investigated whether different clinical or imaging characteristics predict spot sign presence in patients with different underlying vasculopathies. Using ICH location as a surrogate for hypertension-related ICH and cerebral amyloid angiopathy-related ICH, we identified risk factors associated with spot sign. METHODS: We retrospectively analyzed a prospective cohort of consecutive spontaneous ICH patients with available CTA. Spot sign presence was ascertained by two independent readers blinded to clinical data. We assessed potential predictors of spot sign be performing uni- and multivariable logistic regression, analyzing deep and lobar ICH separately. RESULTS: 649 patients were eligible, 291 (45%) deep and 358 (55%) lobar ICH. Median time from symptom onset to CTA was 4.5 (IQR 5.2) and 5.7 (IQR 7.4) hours in patients with deep and lobar ICH, respectively. At least one spot sign was present in 76 (26%) deep and 103 (29%) lobar ICH patients. In mutivariable logistic regression, independent predictors of spot sign in deep ICH were warfarin (OR 2.82 [95%CI 1.06-7.57]; p=0.03), time from symptom onset to CTA (OR 0.9 [95%CI 0.81-0.97]; p=0.02), and baseline ICH volume (OR 1.27 [95%CI 1.14-1.43]; p=2.5E-5; per 10 mL increase). Predictors of spot sign in lobar ICH were preexisting dementia (OR 2.7 [95%CI 1.15-6.43]; p=0.02), warfarin (OR 4.01 [95%CI 1.78-9.29]; p=0.009), and baseline ICH volume (OR 1.27 [95%CI 1.17-1.39]; p=5.4E-8; per 10 mL increase). As expected, spot sign presence was a strong predictor of hematoma expansion in both deep (OR 3.52 [95%CI 1.72-7.2]; p=0.0005) and lobar ICH (OR 6.53 [95%CI 3.23-13.44]; p=2.2E-7). CONCLUSIONS: The most potent associations with spot sign are shared by deep and lobar ICH, suggesting that ICH caused by different vasculopathic processes share biological features. The relationship between preexisting dementia and spot sign in lobar ICH, but not deep ICH, suggests that ICH occurring in the context of more advanced cerebral amyloid angiopathy may be more likely to have prolonged bleeding.

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

ObjectiveThis 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).MethodsWe 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.ResultsWe 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.ConclusionAs 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.

Evolution of Computed Tomography Angiography Spot Sign Is Consistent With a Site of Active Hemorrhage in Acute Intracerebral Hemorrhage

CT angiography spot sign predicts hematoma expansion in patients with acute intracerebral hemorrhage (ICH). The spot sign may represent a site of active extravasation, a locus of arrested hemorrhage forming fibrin globes, or represent associated epiphenomena such as hypertensive microaneurysms. We sought to describe the evolution of spot signs over 60 seconds in acute ICH using dynamic CT angiography and determine whether they grow and diffuse into the hematoma as would be expected with active extravasation. We prospectively identified consecutive patients presenting with spontaneous ICH<6 hours from symptom onset that completed dynamic CT angiography imaging over a 60-second acquisition protocol. We determined spot positivity, quantified spot volumes, and then used repeated-measures ANOVA to assess changes in spot volume over time. We collected data on 35 patients; 13 of 35 (37%) patients were spot-positive. Spot-positive patients had larger median ICH volume compared with spot-negative patients (median 10.7 versus 49.2 mL; P=0.007). Maximal spot sign volumes ranged from 0.02 to 2.8 mL (median 0.17 mL). Spot sign volumes increased significantly with time (P<0.001) and seemed to disperse into the hematoma in all cases. Three of 13 (23%) spot-positive patients presented with 2 distinct spot signs, but the remaining patients either had only 1 spot sign or different contiguous components of an irregularly shaped spot sign. In this dynamic CT angiography study of ICH, spot signs evolve consistent with sites of active extravasation.

Abstract TMP84: A Prediction Score for Hematoma Expansion Following Acute Intracerebral Hemorrhage

Purpose: Hematoma expansion (HE) following acute intracerebral hemorrhage (ICH) is common and associated with poor outcome. Ongoing clinical trials therefore focus on restricting HE. In order to provide treatment options to the patients at highest risk of HE, we aimed to develop a prediction score for HE. Methods: We performed a prospective cohort study of consecutive primary ICH patients presenting to a single center over a 12-year period, with available baseline and follow-up CTs. HE was assessed using semi-automated software and defined as 6 mL or 33% growth. Our cohort was randomly divided in a 2/3 development and 1/3 validation cohort. Uni- and multivariate logistic regression was performed to assess clinical and neuroimaging covariates for relationship with HE. A prediction model was derived based on regression estimates, and this model was subsequently tested in the validation cohort. Results: 817 ICH patients were included: 544 in the development cohort and 273 in the validation cohort. Overall, HE occurred in 156 patients (19%). In multivariate analysis, warfarin use (OR 2.09 [95%CI 1.24-3.52], p = 0.006), shorter time to CT (≤6 vs. &gt;6 hours; OR 2.14 [95%CI 1.18-3.90], p = 0.013), baseline ICH volume (&lt;30, 30-60, &gt;60 mL; OR 1.90 [95%CI 1.01-3.55], p = 0.045), and the CT angiography spot sign (OR 3.59 [95%CI 1.77-7.29], p = 0.0004) were predictive of HE. The derived prediction score (0-9) showed a linear relation with the probability of HE and mortality (at discharge and 90 days), in both the development and the validation cohorts. The probability of HE in the validation cohort was 0%, 10%, 39%, and 54% for categorized scores 0, 1-3, 4-6, and 7-9, respectively. The c statistics were 0.69 for the development cohort and 0.78 for the validation cohort. Conclusion: Warfarin use, presentation within 6 hours after ICH, larger ICH volumes at baseline, and the CT angiography spot sign are independent predictors of HE and mortality. Based on these findings, we developed a prediction score for HE. Since no therapy has demonstrated benefit in a randomized trial, our results open a path for individualized treatment and trial design in ICH, aimed at patients at highest risk of HE.

Clinical Applications of the Computed Tomography Angiography Spot Sign in Acute Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage (ICH) is the most fatal form of stroke, with 1-month morality rates often exceeding 40% and rates of death or severe disability exceeding 75%.1,2 Nearly 20 years ago, the first observational studies demonstrated that hematoma volume on presentation was among the most potent predictors of survival and functional outcome.3 Subsequent studies identified the frequent occurrence of hematoma expansion after the initial computed tomography (CT) scan.4 Occurring in ≤40% of patients, this expansion further contributes to poor outcome.5,6 These observations have made the arrest of expansion the most common target for acute clinical trials in ICH.7–9 Thus far, the specific targeting of hematoma expansion in clinical trials has yet to yield improvement in clinical outcome. This may be attributed to difficulty in identifying those individuals most likely to benefit from the intervention, those who will experience hematoma expansion. Risk factors for expansion include early presentation, baseline hematoma volume, and warfarin use.4,10,11 Even among patients presenting within 3 hours, however, expansion severe enough to cause clinical deterioration occurs in no more than 40%.4,6–8 The CT angiography (CTA) spot sign has emerged in recent years as a potent predictor of hematoma expansion, and a potential tool in guiding therapies in both research and clinical care. ### Definition First described in 1999,12 the CTA spot sign has evolved in its definition from the broader concept of contrast extravasation, comprising high-density material or contrast leakage within the hematoma,12–14 to encompass foci of enhancement within the hematoma on CTA source images.15 Although definitions of the spot sign used in individual studies continue to vary, all are variations on this standard (Table 1). In 2009, a spot sign score was …

CTA Spot Sign Predicts Hematoma Expansion in Patients with Delayed Presentation After Intracerebral Hemorrhage

Hematoma expansion after acute intracerebral hemorrhage occurs most frequently in patients presenting within 3 h of symptom onset. However, the majority of patients present outside this window or with an unknown onset time. We investigated the prevalence of hematoma expansion in these patients and assessed the accuracy of the CT angiography (CTA) spot sign for identifying risk of hematoma expansion. We analyzed 391 consecutive patients undergoing CTA and a followup CT. CTA spot sign readings were performed by two experienced readers and hematoma expansion was assessed by means of semi-automated software. Hematoma expansion occurred in 18 % of patients. When stratified by time from symptom onset to initial CT, hematoma expansion rates were: 39 % within 3 h; 11 % between 3 and 6 h, 11 % beyond 6 h (but with known onset), and 20 % in patients with unknown symptom onset. Of patients who developed hematoma expansion, only 38 % presented within 3 h. The accuracy of the spot sign in predicting hematoma expansion was 0.67 for patients presenting within 3 h, 0.83 between 3 and 6 h, 0.88 after 6 h, and 0.76 for patients presenting with an unknown onset time. A substantial number of patients destined to suffer from hematoma expansion present either late or with an unknown symptom onset time. The CTA spot sign accurately identifies patients destined to expand regardless of time from symptom onset, and may therefore open a path to offer clinical trials and novel therapies to the many patients who do not present acutely.

Stroke: Highlights of Selected Articles

<i>Stroke:</i> Highlights of Selected Articles

Apolipoprotein E Genotype Is Associated With CT Angiography Spot Sign in Lobar Intracerebral Hemorrhage

The CT angiography (CTA) spot sign predicts hematoma expansion and poor outcome in patients with primary intracerebral hemorrhage (ICH). The biological underpinnings of the spot sign remain poorly understood; it may be that the underlying vasculopathy influences its presence. Therefore, we conducted a study to identify genetic predictors of the spot sign. In an ongoing prospective cohort study, we analyzed 371 patients with CTA and genetic data available. CTAs were reviewed for the spot sign by 2 experienced readers, blinded to clinical data, according to validated criteria. Analyses were stratified by ICH location. In multivariate analysis, patients on warfarin were more likely to have a spot sign regardless of ICH location (OR, 3.85; 95% CI, 1.33-11.13 in deep ICH and OR, 2.86; 95% CI, 1.33-6.13 in lobar ICH). Apolipoprotein E ε2, but not ε4, was associated with the presence of a spot sign in lobar ICH (OR, 2.09; 95% CI, 1.05-4.19). There was no effect for ε2 or ε4 in deep ICH. Patients with ICH on warfarin are more likely to present with a spot sign regardless of ICH location. Among patients with lobar ICH, those who possess the apolipoprotein E ε2 allele are more likely to have a spot sign. Given the established relationship between apolipoprotein E ε2 and vasculopathic changes in cerebral amyloid angiopathy, our findings suggest that both hemostatic factors and vessel pathology influence spot sign presence.

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

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. 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. 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). 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. Canadian Stroke Consortium and NovoNordisk Canada.

CT angiography spot sign predicts in-hospital mortality in patients with secondary intracerebral hemorrhage

Background and objectiveThe presence of active contrast extravasation during CT angiography, the spot sign, is a potent predictor of in-hospital mortality in patients with primary intracerebral hemorrhage (ICH). However, its...