Computed Tomography Angiography Spot Sign, Hematoma Expansion, and Functional Outcome in Spontaneous Cerebellar Intracerebral Hemorrhage

Background and Purpose: The computed tomography angiography spot sign is associated with hematoma expansion, case fatality, and poor functional outcome in spontaneous supratentorial intracerebral hemorrhage (ICH). However, no data are available on the spot sign in spontaneous cerebellar ICH. Methods: We investigated consecutive patients with spontaneous cerebellar ICH at 3 academic hospitals between 2002 and 2017. We determined patient characteristics, hematoma expansion (>33% or 6 mL), rate of expansion, discharge and 90-day case fatality, and functional outcome. Poor functional outcome was defined as a modified Rankin Scale score of 4 to 6. Associations were tested using univariable and multivariable logistic regression. Results: Three hundred fifty-eight patients presented with cerebellar ICH, of whom 181 (51%) underwent a computed tomography angiography. Of these 181 patients, 121 (67%) were treated conservatively of which 15 (12%) had a spot sign. Patients with a spot sign treated conservatively presented with larger hematoma volumes (median [interquartile range]: 26 [7–41] versus 6 [2–13], P =0.001) and higher speed of expansion (median [interquartile range]: 15 [24–3] mL/h versus 1 [5–0] mL/h, P =0.034). In multivariable analysis, presence of the spot sign was independently associated with death at 90 days (odds ratio, 7.6 [95% CI, 1.6–88], P =0.037). With respect to surgically treated patients (n=60, [33%]), 14 (23%) patients who underwent hematoma evacuation had a spot sign. In these 60 patients, patients with a spot sign were older (73.5 [9.2] versus 66.6 [15.4], P =0.047) and more likely to be female (71% versus 37%, P =0.033). In a multivariable analysis, the spot sign was independently associated with death at 90 days (odds ratio, 2.1 [95% CI, 1.1–4.3], P =0.033). Conclusions: In patients with spontaneous cerebellar ICH treated conservatively, the spot sign is associated with speed of hematoma expansion, case fatality, and poor functional outcome. In surgically treated patients, the spot sign is associated with 90-day case fatality.

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Abstract 182: "Spot" Sign vs "Dot" Sign as Predictor of Hemorrhagic Stroke Outcomes

Stroke ◽

10.1161/str.45.suppl_1.182 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Katherine O Brag ◽

Erica Jones ◽

Dominique Monlezun ◽

Alex George ◽

Michael Halstead ◽

...

Keyword(s):

Functional Outcome ◽

Clinical Significance ◽

Statistical Tests ◽

Hematoma Expansion ◽

Poor Functional Outcome ◽

Spot Sign ◽

Post Contrast ◽

Stroke Registry ◽

Logistic Regression Models

Introduction: Hematoma expansion (HE) is an established predictor of mortality and poor functional outcome after intracerebral hemorrhage (ICH). The computed tomography angiography (CTA) “spot” sign predicts HE and deterioration. The “dot” sign on delayed post-contrast CT (PCCT) has undetermined clinical significance but is thought to represent a slower rate of bleeding than the “spot” sign. We aimed to compare the sensitivity of a “dot” sign with the “spot” sign and establish the clinical significance of the “dot” sign. Methods: Patients with ICH presenting to our center July 2008-May 2013 were identified from our stroke registry. Only patients with baseline CT, CTA and PCCT and follow-up CT 6-36 hours later were included. Patients with clot evacuation between baseline and follow-up CT were excluded. HE was defined as 1) any ≥ 1cc increase and 2) significant ≥ 12.5cc increase or >33% increase in volume. Differences in cohort characteristics were assessed using appropriate statistical tests and sensitivity was calculated from 2x2 tables. Unadjusted logistic regression models were used to investigate the relation of “spot” and “dot” signs with HE and poor functional outcome (discharge mRS 4-6). Results: Of the 210 ICH patients included in the analyses (median age 61, 44.7% female, 66.2% black), 39 (18.5%) patients had a PCCT “dot” sign and 19 (9%) had a CTA “spot” sign. Significant HE occurred in 15% with “dot” sign and 8% with “spot” sign. The PCCT “dot” sign had a sensitivity of 0.52 in predicting significant HE and a sensitivity of 0.69 in predicting discharge mRS 4-6 (compared with 0.24 and 0.30 for “spot” sign, respectively). Patients with a “dot” sign, but without a “spot” sign, had significantly increased odds of any HE (OR 5.7, 95% CI 1.9-17.8, p=0.003), mRS 4-6 (OR 8.1, 95% CI 1.03-64.6, p=0.048), and death (OR 8.1, 95% CI 1.4-48.4, p=0.02), but not significant HE (OR 2.2, 95% CI 0.7-6.7, p=0.15). Conclusions: The PCCT “dot” sign was more sensitive in predicting hematoma expansion than the CTA “spot” sign and predicted hematoma expansion and poor functional outcome even in the absence of the “spot sign.” The utility of PCCT imaging in acute evaluation of ICH patients requires validation, but our study supports clinical relevance of the “dot” sign.

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Spot Sign on 90-Second Delayed Computed Tomography Angiography Improves Sensitivity for Hematoma Expansion and Mortality

Stroke ◽

10.1161/strokeaha.114.005570 ◽

2014 ◽

Vol 45 (11) ◽

pp. 3293-3297 ◽

Cited By ~ 31

Author(s):

Viesha A. Ciura ◽

H. Bart Brouwers ◽

Raffaella Pizzolato ◽

Claudia J. Ortiz ◽

Jonathan Rosand ◽

...

Keyword(s):

Computed Tomography ◽

Computed Tomography Angiography ◽

Hematoma Expansion ◽

Spot Sign

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Tranexamic Acid for Prevention of Hematoma Expansion in Intracerebral Hemorrhage Patients With or Without Spot Sign

Stroke ◽

10.1161/strokeaha.120.032426 ◽

2021 ◽

Author(s):

Christian Ovesen ◽

Janus Christian Jakobsen ◽

Christian Gluud ◽

Thorsten Steiner ◽

Zhe Law ◽

...

Keyword(s):

Computed Tomography ◽

Intracerebral Hemorrhage ◽

Tranexamic Acid ◽

Symptom Onset ◽

Odds Ratio ◽

Hematoma Expansion ◽

Spot Sign ◽

Main Trial ◽

Acid Versus ◽

Acute Intracerebral Hemorrhage

Background and Purpose: The computed tomography angiography or contrast-enhanced computed tomography based spot sign has been proposed as a biomarker for identifying on-going hematoma expansion in patients with acute intracerebral hemorrhage. We investigated, if spot-sign positive participants benefit more from tranexamic acid versus placebo as compared to spot-sign negative participants. Methods: TICH-2 trial (Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage) was a randomized, placebo-controlled clinical trial recruiting acutely hospitalized participants with intracerebral hemorrhage within 8 hours after symptom onset. Local investigators randomized participants to 2 grams of intravenous tranexamic acid or matching placebo (1:1). All participants underwent computed tomography scan on admission and on day 2 (24±12 hours) after randomization. In this sub group analysis, we included all participants from the main trial population with imaging allowing adjudication of spot sign status. Results: Of the 2325 TICH-2 participants, 254 (10.9%) had imaging allowing for spot-sign adjudication. Of these participants, 64 (25.2%) were spot-sign positive. Median (interquartile range) time from symptom onset to administration of the intervention was 225.0 (169.0 to 310.0) minutes. The adjusted percent difference in absolute day-2 hematoma volume between participants allocated to tranexamic versus placebo was 3.7% (95% CI, −12.8% to 23.4%) for spot-sign positive and 1.7% (95% CI, −8.4% to 12.8%) for spot-sign negative participants ( P heterogenity =0.85). No difference was observed in significant hematoma progression (dichotomous composite outcome) between participants allocated to tranexamic versus placebo among spot-sign positive (odds ratio, 0.85 [95% CI, 0.29 to 2.46]) and negative (odds ratio, 0.77 [95% CI, 0.41 to 1.45]) participants ( P heterogenity =0.88). Conclusions: Data from the TICH-2 trial do not support that admission spot sign status modifies the treatment effect of tranexamic acid versus placebo in patients with acute intracerebral hemorrhage. The results might have been affected by low statistical power as well as treatment delay. REGISTRATION: URL: http://www.controlled-trials.com ; Unique identifier: ISRCTN93732214.

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Computed Tomography Angiography Spot Sign as a Predictor of Hematoma Expansion and Outcome in Spontaneous Intracerebral Hemorrhage

Zagazig University Medical Journal ◽

10.21608/zumj.2019.18839.1608 ◽

2019 ◽

Vol 0 (0) ◽

pp. 0-0

Author(s):

Wael Ibrahim ◽

EL Hady Abdel Gawad ◽

Amal ELmotayam ◽

El Sayed Zidan ◽

Wael Mahmoud

Keyword(s):

Computed Tomography ◽

Intracerebral Hemorrhage ◽

Computed Tomography Angiography ◽

Hematoma Expansion ◽

Spontaneous Intracerebral Hemorrhage ◽

Spot Sign

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Prevalence and diagnostic performance of computed tomography angiography spot sign for intracerebral hematoma expansion depend on scan timing

Neuroradiology ◽

10.1007/s00234-014-1430-3 ◽

2014 ◽

Vol 56 (12) ◽

pp. 1039-1045 ◽

Cited By ~ 16

Author(s):

Akio Tsukabe ◽

Yoshiyuki Watanabe ◽

Hisashi Tanaka ◽

Yuki Kunitomi ◽

Mitsuo Nishizawa ◽

...

Keyword(s):

Computed Tomography ◽

Computed Tomography Angiography ◽

Diagnostic Performance ◽

Hematoma Expansion ◽

Intracerebral Hematoma ◽

Spot Sign

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Added value of delayed computed tomography angiography in primary intracranial hemorrhage and hematoma size for predicting spot sign

Acta Radiologica ◽

10.1177/0284185117718401 ◽

2017 ◽

Vol 59 (4) ◽

pp. 485-490 ◽

Cited By ~ 2

Author(s):

Te Chang Wu ◽

Tai Yuan Chen ◽

Yow Ling Shiue ◽

Jeon Hor Chen ◽

Tsyh-Jyi Hsieh ◽

...

Keyword(s):

Computed Tomography ◽

Hospital Mortality ◽

Clinical Outcomes ◽

Computed Tomography Angiography ◽

Area Under The Curve ◽

Predictive Performance ◽

Added Value ◽

Hematoma Expansion ◽

Contrast Extravasation ◽

Spot Sign

Background The computed tomography angiography (CTA) spot sign represents active contrast extravasation within acute primary intracerebral hemorrhage (ICH) and is an independent predictor of hematoma expansion (HE) and poor clinical outcomes. The spot sign could be detected on first-pass CTA (fpCTA) or delayed CTA (dCTA). Purpose To investigate the additional benefits of dCTA spot sign in primary ICH and hematoma size for predicting spot sign. Material and Methods This is a retrospective study of 100 patients who underwent non-contrast CT (NCCT) and CTA within 24 h of onset of primary ICH. The presence of spot sign on fpCTA or dCTA, and hematoma size on NCCT were recorded. The spot sign on fpCTA or dCTA for predicting significant HE, in-hospital mortality, and poor clinical outcomes (mRS ≥ 4) are calculated. The hematoma size for prediction of CTA spot sign was also analyzed. Results Only the spot sign on dCTA could predict high risk of significant HE and poor clinical outcomes as on fpCTA ( P < 0.05). With dCTA, there is increased sensitivity and negative predictive value (NPV) for predicting significant HE, in-hospital mortality, and poor clinical outcomes. The XY value (product of the two maximum perpendicular axial dimensions) is the best predictor (area under the curve [AUC] = 0.82) for predicting spot sign on fpCTA or dCTA in the absence of intraventricular and subarachnoid hemorrhage. Conclusion This study clarifies that dCTA imaging could improve predictive performance of CTA in primary ICH. Furthermore, the XY value is the best predictor for CTA spot sign.

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Computed Tomography Angiography Spot Sign Does Not Predict Case Fatality in Aneurysmal Subarachnoid Hemorrhage With Intraparenchymal Extension

Stroke ◽

10.1161/strokeaha.111.000586 ◽

2013 ◽

Vol 44 (6) ◽

pp. 1590-1594 ◽

Cited By ~ 6

Author(s):

H. Bart Brouwers ◽

Daan Backes ◽

W. Taylor Kimberly ◽

Kristin Schwab ◽

Javier M. Romero ◽

...

Keyword(s):

Computed Tomography ◽

Subarachnoid Hemorrhage ◽

Computed Tomography Angiography ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Case Fatality ◽

Spot Sign

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Spot Sign Number Is the Most Important Spot Sign Characteristic for Predicting Hematoma Expansion Using First-Pass Computed Tomography Angiography

Stroke ◽

10.1161/strokeaha.111.000410 ◽

2013 ◽

Vol 44 (4) ◽

pp. 972-977 ◽

Cited By ~ 43

Author(s):

Thien J. Huynh ◽

Andrew M. Demchuk ◽

Dar Dowlatshahi ◽

David J. Gladstone ◽

Özlem Krischek ◽

...

Keyword(s):

Computed Tomography ◽

Computed Tomography Angiography ◽

Hematoma Expansion ◽

Spot Sign ◽

First Pass

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Intracranial Thrombus Extent Predicts Clinical Outcome, Final Infarct Size and Hemorrhagic Transformation in Ischemic Stroke: The Clot Burden Score

International Journal of Stroke ◽

10.1111/j.1747-4949.2008.00221.x ◽

2008 ◽

Vol 3 (4) ◽

pp. 230-236 ◽

Cited By ~ 164

Author(s):

Volker Puetz ◽

Imanuel Dzialowski ◽

Michael D. Hill ◽

Suresh Subramaniam ◽

P.N. Sylaja ◽

...

Keyword(s):

Computed Tomography ◽

Ischemic Stroke ◽

Carotid Artery ◽

Functional Outcome ◽

Scale Score ◽

Computed Tomography Angiography ◽

Odds Ratio ◽

Internal Carotid ◽

Final Infarct Size ◽

Clot Burden

Background In ischemic stroke, functional outcomes vary depending on site of intracranial occlusion. We tested the prognostic value of a semiquantitative computed tomography angiography-based clot burden score. Methods Clot burden score allots major anterior circulation arteries 10 points for presence of contrast opacification on computed tomography angiography. Two points each are subtracted for thrombus preventing contrast opacification in the proximal M1, distal M1 or supraclinoid internal carotid artery and one point each for M2 branches, A1 and infraclinoid internal carotid artery. We retrospectively studied patients with disabling neurological deficits (National Institute of Health Stroke Scale score ≥ 5) and computed tomography angiography within 24-hours from symptom onset. We analyzed percentages independent functional outcome (modified Rankin Scale score ≤ 2), final infarct Alberta Stroke Program Early Computed Tomography Score and parenchymal hematoma rates across categorized clot burden score groups and performed multivariable analysis. Results We identified 263 patients (median age 73-years, National Institute of Health Stroke Scale score 10, onset-to-computed tomography angiography time 165 min). Clot burden score < 10 was associated with reduced odds of independent functional outcome (odds ratio 0.09 for clot burden score ≤5; odds ratio 0.22 for clot burden score 6–7; odds ratio 0.48 for clot burden score 8–9; all versus clot burden score 10; P <0.02 for all). Lower clot burden scores were associated with lower follow-up Alberta Stroke Program Early CT Scores ( P <0.001) and higher parenchymal hematoma rates ( P = 0.008). Inter-rater reliability for clot burden score was 0.87 (lower 95% confidence interval 0.71) and intra-rater reliability 0.96 (lower 95% confidence interval 0.92). Conclusion The quantification of intracranial thrombus extent with the clot burden score predicts functional outcome, final infarct size and parenchymal hematoma risk acutely. The score needs external validation and could be useful for patient stratification in stroke trials.

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