Abstract TP337: Multiphase CTA Improves ICH Expansion Prediction and Might Provide Additional Information on the Pathophysiology of the Spot Sign

Background: Although the spot sign is a strong predictor of hematoma expansion, there is no accepted consensus on the timing of CTA acquisition, mainly because its pathophysiologic significance is uncertain. We investigated the yield of the spot sign in the prediction of hematoma expansion and its pathophysiological underpinnings using multiphase CTA. Methods: Single-center prospective observational cohort study of 123 consecutive patients with acute (<6 hours) ICH. Patients underwent multiphase CTA performed in 3 automated phases after contrast dye injection (delay of 8, 4, and 15 seconds, respectively). According to spot sign positivity in the 3 phases, patients were categorized into 1 of 4 patterns: A (+/+/-), B (+/+/+), C (-/+/+), and D (-/-/+). Outcomes included frequency of the spot sign, significant hematoma expansion at 24 hours (>33% or >6 mL, primary outcome), and absolute hematoma growth. Results: The frequency of the spot sign was higher the later the phase of CTA was: 29.3% in phase 1, 43.1% in 2, and 46.3% in 3 ( P <0.001). The presence of the spot sign in phase 1, 2, 3, or any phase was related to significant hematoma expansion ( P <0.001 for all comparisons). Predictive values varied depending on the CTA phase, with highest PPV observed in phase 1 (63%) and highest NPV in phase 2 (88.9%). Onset to imaging time was not significantly lower the more arterial the pattern of spot sign presentation was (Figure). The frequency of significant hematoma expansion was higher the earlier the pattern of spot sign presentation: A 100%, B 59.1%, C 40%, and D 0% ( P =0.013). Absolute hematoma growth analysis showed a hierarchical distribution of patterns of spot sign presentation: A > B > C > D > no spot sign ( P =0.003, Figure). Conclusions: Multiphase CTA improves hematoma expansion prediction and might provide additional information on the pathophysiology of the spot sign. Arterial spot signs may represent the point of active hemorrhage, and venous spot signs the site of resolved bleeding.

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Abstract P533: Incidence and Outcomes of Thrombectomy Rescue Therapies in Acute Basilar Artery Occlusions

Stroke ◽

10.1161/str.52.suppl_1.p533 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Ronda Lun ◽

Greg B Walker ◽

David Weisenburger-Lile ◽

Bertrand Lapergue ◽

Adrien Guenego ◽

...

Keyword(s):

Primary Outcome ◽

Secondary Analysis ◽

Hematoma Expansion ◽

Primary Analysis ◽

Predictive Values ◽

Previous Definition ◽

Secondary Analyses ◽

Revised Definitions ◽

Definition Of ◽

Sensitivity Specificity

Background: Hematoma expansion (HE) is an important therapeutic target in intracerebral hemorrhage. Recently proposed HE definitions have not been validated, and no previous definition has accounted for withdrawal of care (WOC). Objective: To compare conventional and revised definitions of hematoma expansion (HE), while accounting for WOC. Methods: We analyzed data from the ATACH-2 trial, comparing revised definitions of HE incorporating intraventricular hemorrhage (IVH) expansion to the conventional definition of “≥6 mL or ≥33%”. The primary outcome was modified Rankin Scale of 4-6 at 90-days. We calculated the incidence, sensitivity, specificity, positive and negative predictive values, and c- statistic for all definitions of HE. Definitions were compared using non-parametric methods. Secondary analyses were performed after removing patients who experienced WOC. Results: Primary analysis included 948 patients. Using the conventional definition, the sensitivity was 37.1% and specificity was 83.2% for the primary outcome. Sensitivity improved with all three revised definitions (53.3%, 48.7%, and 45.3%, respectively), with minimal change to specificity (78.4%, 80.5%, and 81.0%, respectively). The greatest improvement was seen with the definition “≥6 mL or ≥33% or any IVH”, with increased c -statistic from 60.2% to 65.9% (p < 0.001). Secondary analysis excluded 46 participants who experienced WOC. The revised definitions outperformed the conventional definition in this population as well, with the greatest improvement in c -statistic using “≥6 mL or ≥33% or any IVH” (58.1% vs 64.1%, p < 0.001). Conclusions: HE definitions incorporating intraventricular expansion outperformed conventional definitions for predicting poor outcome, even after accounting for care limitations.

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Abstract 114: The Predictive Ability of the CTA Spot Sign for Hematoma Expansion is Dependent on Time Since ICH Onset: A Systematic Review and Patient-level Meta-analysis.

Stroke ◽

10.1161/str.44.suppl_1.a114 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Dar Dowlatshahi ◽

Bart Brouwers ◽

Andrew Demchuk ◽

Michael D Hill ◽

Richard Aviv ◽

...

Keyword(s):

Meta Analysis ◽

Predictive Ability ◽

Cochrane Library ◽

Hematoma Expansion ◽

Cochrane Central Register ◽

Contrast Extravasation ◽

Spot Sign ◽

Predictive Values ◽

Patient Level ◽

Chi Square Analysis

Background: Hematoma expansion (HE) occurs in up to 40% of patients with intracerebral hemorrhage (ICH), and predicts poor clinical outcome. Contrast extravasation following CT-angiography (CTA), termed “spot sign”, identifies patients at highest risk of HE. However, the prevalence and predictive values of the spot sign varies across studies, possibly due to differences in onset-to-CTA time. We therefore performed a patient-level meta-analysis to define the relationship between onset-to-CTA time and the prevalence & predictive value of spot sign, and the size of HE. Methods: We searched the Cochrane Central Register of Controlled Trials, the Cochrane Library Database of Systematic Reviews, MEDLINE and EMBASE for studies of CTA spot sign prevalence and HE. We pooled data on the prevalence and predictive values for significant HE (defined as either 6mL or 33% growth of ICH) for patients with ICH stratified by onset-to-CTA time: <3hours, 3-6 hours, >6hours. We used chi-square analysis to assess the spot sign in each time strata, and two-way ANOVA to compare across time strata. Results: We identified ICH spot sign databases derived from 7 countries and 14 centers (n=705). Prevalence of spot sign decreased with increasing onset-to-CTA time (Table; p<0.001). The subset with follow-up scans used for HE analysis (n=582) revealed spot sign sensitivity and PPV were highest in the earliest time strata, whereas specificity and NPV were highest in the latest time strata (Table). Spot positive patients had greatest absolute HE in the earlier CTA time strata (median spot positive growth 6.8mL, 5.6mL, 5.2mL for 6hr respectively; p<0.001; means in Table). Conclusion: Prevalence, predictive values and magnitude of effect of the spot sign are dependent on onset-to-CTA timing; these results are relevant to both ICH trial design and acute management.

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Abstract WMP83: Prediction of Intracerebral Hematoma Expansion: Multicenter External Validation of the CTA Spot Sign Score

Stroke ◽

10.1161/str.44.suppl_1.awmp83 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Thien J Huynh ◽

Andrew Demchuk ◽

Dar Dowlatshahi ◽

Ölem Krischek ◽

Alex Kiss ◽

...

Keyword(s):

External Validation ◽

Area Under The Curve ◽

Hematoma Expansion ◽

Intracerebral Hematoma ◽

Spot Sign ◽

Perfect Agreement ◽

Sagittal Sinus ◽

Spot Number ◽

Hematoma Growth ◽

Contrast Ct

Background and Purpose: The spot sign score (SSS) stratifies hematoma expansion risk in patients with acute intracerebral hemorrhage (ICH) but is not externally validated. We sought to validate the SSS and assess prognostic spot characteristics associated with hematoma expansion in a prospective multicenter study. Methods: We studied 228 ICH patients presenting < 6 hours post-onset enrolled in the PREDICT (PREdicting hematoma growth anD outcome in ICH using contrast bolus CT) study, a multicentre prospective observational cohort study of ICH patients evaluated with baseline non-contrast CT, CT angiography (CTA), and 24-hour follow-up CT. Primary outcome was significant hematoma expansion (>6ml or >33%). Secondary outcomes were absolute and relative expansion. Blinded CTA spot sign characterization (spot number, maximum axial size and attenuation, and relative attenuation compared to the ipsilateral internal carotid artery and superior sagittal sinus) and SSS calculation was performed independently by two neuroradiologists and a radiology resident. Multivariable regression for prediction of hematoma expansion was performed and diagnostic performance of the SSS and spot characteristics was examined with ROC analysis and tests for trend. Results: SSS independently predicted significant, absolute, and relative hematoma expansion (p-values of 0.001, <0.001, and 0.009, respectively), adjusting for initial hematoma volume, INR, mean arterial pressure, and time from onset-to-baseline CT, and demonstrated near perfect interobserver agreement (κ = 0.82). Spot number and SSS demonstrated similar area under the curve (AUC 0.69 vs. 0.68, p=0.149) for hematoma expansion. Incremental risk of hematoma expansion was demonstrated with increasing SSS however a significant trend was not identified (p trend=0.720). Of all spot characteristics, only spot number was independently associated with expansion (p<0.001) providing incremental risk stratification (p trend=0.050) and near perfect agreement (κ=0.85). Median absolute hematoma growth for 0, 1, 2 to 3, ≥4 spots was 0.4, 4, 12, 82 ml respectively. Conclusion: Spot number is the single best predictor of significant ICH expansion and appears to be as good as the total SSS in predicting expansion.

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

BioMed Research International ◽

10.1155/2017/4137210 ◽

2017 ◽

Vol 2017 ◽

pp. 1-9 ◽

Cited By ~ 7

Author(s):

Wen-Jie Peng ◽

Cesar Reis ◽

Haley Reis ◽

John Zhang ◽

Jun Yang

Keyword(s):

Intracerebral Hemorrhage ◽

Clinical Judgment ◽

Independent Predictor ◽

Hematoma Expansion ◽

Contrast Extravasation ◽

Spot Sign ◽

Mortality And Morbidity ◽

Active Hemorrhage ◽

Hemorrhagic Risk ◽

Higher Sensitivity

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.

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Predictive Ability of Ultraearly Hematoma Growth and Spot Sign for Redefined Hematoma Expansion in Patients with Spontaneous Intracerebral Hemorrhage

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2021.105950 ◽

2021 ◽

Vol 30 (9) ◽

pp. 105950

Author(s):

Junhong Li ◽

Xiang Liao ◽

Zhiyuan Yu ◽

Hao Li ◽

Jun Zheng

Keyword(s):

Intracerebral Hemorrhage ◽

Predictive Ability ◽

Hematoma Expansion ◽

Spontaneous Intracerebral Hemorrhage ◽

Spot Sign ◽

Hematoma Growth

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Revised intracerebral hemorrhage expansion definitions: Relationship with care limitations

International Journal of Stroke ◽

10.1177/1747493020967255 ◽

2020 ◽

pp. 174749302096725

Author(s):

Ronda Lun ◽

Vignan Yogendrakumar ◽

Greg Walker ◽

Michel Shamy ◽

Robert Fahed ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Intraventricular Hemorrhage ◽

Primary Outcome ◽

Secondary Analysis ◽

Hematoma Expansion ◽

Primary Analysis ◽

Predictive Values ◽

C Statistic ◽

Revised Definitions ◽

Sensitivity Specificity

Background Hematoma expansion is an important therapeutic target in intracerebral hemorrhage. Recently proposed hematoma expansion definitions have not been validated, and no previous definition has accounted for withdrawal of care. Aims To externally validate revised definitions of hematoma expansion that incorporate intraventricular hemorrhage, and to test their validity in the context of withdrawal of care. Methods We analyzed data from the Antihypertensive Treatment of Acute Cerebral Hemorrhage II trial, comparing revised definitions of hematoma expansion incorporating intraventricular hemorrhage expansion to the conventional definition of “≥6 mL or ≥33%.” Primary outcome was modified Rankin Scale of 4–6 at 90 days. We calculated the incidence, sensitivity, specificity, positive and negative predictive values, and c-statistic for all definitions of hematoma expansion. Definitions were compared using nonparametric methods. Secondary analyses were performed after removing patients with withdrawal of care. Results Primary analysis included 948 patients. Using the conventional definition, the sensitivity was 37.1% and specificity was 83.2% for the primary outcome. Sensitivity improved with all three revised definitions (53.3%, 48.7%, and 45.3%, respectively), with minimal change to specificity (78.4%, 80.5%, and 81.0%, respectively). The greatest improvement was seen with the definition “≥6 mL or ≥33% or any intraventricular hemorrhage,” with increased c-statistic from 60.2% to 65.9% ( p < 0.001). Secondary analysis excluded 46 participants who experienced withdrawal of care. The revised definitions similarly outperformed the conventional definition in this population, with the greatest improvement in c-statistic using “≥6 mL or ≥33% or any intraventricular hemorrhage” (58.1% vs. 64.1%, p < 0.001). Conclusions Revised hematoma expansion definitions incorporating intraventricular hemorrhage expansion outperformed conventional definitions for predicting poor outcome, even after accounting for care limitations.

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Calculation of Prognostic Scores, Using Delayed Imaging, Outperforms Baseline Assessments in Acute Intracerebral Hemorrhage

Stroke ◽

10.1161/strokeaha.119.027119 ◽

2020 ◽

Vol 51 (4) ◽

pp. 1107-1110 ◽

Cited By ~ 1

Author(s):

Ronda Lun ◽

Vignan Yogendrakumar ◽

Andrew M. Demchuk ◽

Richard I. Aviv ◽

David Rodriguez-Luna ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Predictive Accuracy ◽

Area Under The Curve ◽

Prognostic Scores ◽

Hematoma Expansion ◽

Imaging Data ◽

Spot Sign ◽

Delayed Imaging ◽

Predictive Values ◽

Ich Score

Background and Purpose— Patients with intracerebral hemorrhage (ICH) are often subject to rapid deterioration due to hematoma expansion. Current prognostic scores are largely based on the assessment of baseline radiographic characteristics and do not account for subsequent changes. We propose that calculation of prognostic scores using delayed imaging will have better predictive values for long-term mortality compared with baseline assessments. Methods— We analyzed prospectively collected data from the multicenter PREDICT study (Prediction of Hematoma Growth and Outcome in Patients With Intracerebral Hemorrhage Using the CT-Angiography Spot Sign). We calculated the ICH Score, Functional Outcome in Patients With Primary Intracerebral Hemorrhage (FUNC) Score, and modified ICH Score using imaging data at initial presentation and at 24 hours. The primary outcome was mortality at 90 days. We generated receiver operating characteristic curves for all 3 scores, both at baseline and at 24 hours, and assessed predictive accuracy for 90-day mortality with their respective area under the curve. Competing curves were assessed with nonparametric methods. Results— The analysis included 280 patients, with a 90-day mortality rate of 25.4%. All 3 prognostic scores calculated using 24-hour imaging were more predictive of mortality as compared with baseline: the area under the curve was 0.82 at 24 hours (95% CI, 0.76–0.87) compared with 0.78 at baseline (95% CI, 0.72–0.84) for ICH Score, 0.84 at 24 hours (95% CI, 0.79–0.89) compared with 0.76 at baseline (95% CI, 0.70–0.83) for FUNC, and 0.82 at 24 hours (95% CI, 0.76–0.88) compared with 0.74 at baseline (95% CI, 0.67–0.81) for modified ICH Score. Conclusions— Calculation of the ICH Score, FUNC Score, and modified ICH Score using 24-hour imaging demonstrated better prognostic value in predicting 90-day mortality compared with those calculated at presentation.

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Abstract WP293: Baseline Perihematomal Edema is Greater in the Presence of a CTA Spot Sign but Does Not Predict Hematoma Expansion Independent of ICH Volume

Stroke ◽

10.1161/str.44.suppl_1.awp293 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

David Rodriguez-Luna ◽

Teri Stewart ◽

Suresh Subramaniam ◽

Dar Dowlatshahi ◽

Jayme C Kosior ◽

...

Keyword(s):

Ct Scan ◽

Small Degree ◽

Hematoma Expansion ◽

Study Cohort ◽

Lesion Volume ◽

Spot Sign ◽

Observational Cohort ◽

Axial Ct ◽

Perihematomal Edema

Background: Similarly to intracerebral hemorrhage (ICH), perihematomal edema (PHE) increases with time from onset. A small degree of PHE relative to ICH may suggest a very early timepoint from onset or actively bleeding ICH and therefore predict a higher likelihood of hematoma expansion (HE). The relationship between PHE, ICH and HE has not however been established. Therefore, we aimed to investigate the link between PHE and ICH by time and their relationship with the CTA spot sign and HE. Methods: The PREDICT study was a multicentric, prospective, observational cohort study of ICH patients <6 hours. All study cohort subjects with available baseline CT scan images (n=377) were included in this analysis. Volumes and diameters of total lesion, ICH and PHE were measured systematically by two blinded investigators, respectively. Diameter measurements were taken in the axial CT slice with the largest ICH area. Significant HE was defined as ICH enlargement >33% or >6mL at 24 hours. Results: Correlation between volume and diameter measurements was strong for total lesion (r=0.9; p<0.001) and ICH (r=0.88; p<0.001), but moderate for PHE (r=0.43; p<0.001). PHE represented a half of the total lesion volume at baseline (Table). PHE volume and diameter were not related to time from onset to baseline CT, although PHE/ICH diameter (p=0.017) and volume (p=0.061) ratios were higher the later the baseline CT scan was performed. Spot-sign patients (29.7%) had more baseline PHE, ICH and total lesion than spot-negative patients (Table). HE analysis was limited to 322 patients with follow-up CT before rFVIIa or surgical intervention. HE patients (32%) presented with higher PHE, ICH and total lesion volumes (Table). Baseline PHE diameter and volume ratios however did not predict subsequent HE. Conclusion: Edema represents about half of total lesion volume in acute ICH. Edema and ICH are larger in the presence of a CTA spot sign. Edema alone does not predict subsequent hematoma expansion.

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Abstract WP409: Hematoma Expansion After Spontaneous Intracerebral Hemorrhage in Children

Stroke ◽

10.1161/str.44.suppl_1.awp409 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Lori C Jordan ◽

Lauren A Beslow ◽

Melissa C Gindville ◽

Jonathan T Kleinman ◽

Rachel A Bastian ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Volumetric Analysis ◽

Hematoma Expansion ◽

Spot Sign ◽

Research Areas ◽

Hematoma Growth ◽

Receive Treatment ◽

Hypertensive Intracerebral Hemorrhage ◽

To Receive

Objective: Hematoma expansion and its predictors like the “spot sign” are important research areas in adults with primary (hypertensive) intracerebral hemorrhage (ICH), but are rarely studied in secondary ICH. At one center, in adults with ICH due to brain arteriovenous malformation (AVM), aneurysm, or tumor, significant hematoma expansion (>33%) occurred in 6/30 (20%) within 24 hours. In children, the frequency of hematoma expansion and the appropriate timing of follow-up neuroimaging are unknown. We assessed the frequency and extent of hematoma expansion in children with non-traumatic ICH. Methods: From 2007 to 2012, 73 children with spontaneous ICH were enrolled in a three-center prospective study (≥37 weeks gestation-17 years). Inclusion for this sub-study: 2 head CTs obtained for clinical indications within 48 hours after presentation with ICH (28 children). Exclusion: Surgical evacuation of hematoma before 2 nd CT was obtained (2 children), IVH only (7 children), neonates <29 days old (20 children). Hematoma volume was assessed via manual volumetric analysis. Results: Of 73 children, 25 (34%) met all inclusion and exclusion criteria. Median age was 9.0 years, interquartile range (IQR) 2.1-14.1. Median time from symptom onset to first CT was 9.4 hours (IQR 4.5-20). ICH was due to coagulopathy or vascular cause in 22/25 children (88%). Median baseline ICH volume was 22.2mL (range 2-86mL). Hematoma expansion occurred in 7/25 (28%) with 2 head CTs. Median ICH volume expansion was 4mL (range 0.1-12mL), 32% (range 2-58%) of baseline ICH volume. Three had significant (>33%) expansion; all had coagulopathy or vascular etiologies of ICH. As expected, children with 2 head CTs had larger baseline ICH volumes (p=0.05) and were more likely to receive treatment for elevated intracranial pressure (ICP) (p=0.001) compared to children with ICH who had fewer than 2 head CTs within 48 hours. Conclusion: Hematoma expansion occurred in 28% of children with clinical concern for hematoma growth and was >33% in 12%. Repeat CT should be considered in those with large ICH and increased ICP. Head CTs were not obtained at prescribed time intervals; research CTs without clear benefit are not feasible in children.

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