A Study of CT- Angiography Spot sign as a predictor of Hematoma expansion in patients with primary intracerebral Haemorrhage

Introduction: Hematoma expansion is a predictor of poor clinical outcome in intracerebral hemorrhage (ICH). The CT angiography (CTA) spot sign is a validated predictor of hematoma expansion, but its predictive performance is modest. This is in part because traditional “static” CTA can miss delayed spot signs, depending on the timing of image acquisition. Dynamic CTA (dCTA) can detect delayed spot sign formation and allows calculation of contrast extravasation rate. However, the predictive performance of a delayed “dynamic spot” and the relationship between rate of extravasation and hematoma expansion are not known. Our primary objective was to calculate the prevalence and predictive performance of the dynamic spot sign with dCTA. Our secondary objective was to determine whether the rate of contrast extravasation predicts significant hematoma expansion. Methods: We prospectively enrolled 79 patients who presented with primary ICH and underwent dCTA within 6 hours from onset. Primary outcomes were the prevalence of dCTA spot sign and its predictive performance for significant hematoma expansion (increase in hematoma by 6mL or 33% from baseline). For the secondary objective, we calculated the rate of contrast extravasation as the slope of the time curve from the first appearance of contrast at a spot sign to the maximal volume of contrast in 19 acquisitions over 60 seconds. We assessed the relationship between rate of extravasation and hematoma expansion using Mann-Whitney U test and logistic regression. Results: The prevalence of the dCTA spot sign was 45.6% (95% CI, 34.5-56.6%). Significant HE was seen in 58.1% (18/31) of spot-positive patients versus 29.0% (9/31) of spot-negative patients (P=0.04). The sensitivity and specificity of the dCTA spot sign in predicting significant HE was 67% and 63%, respectively. Median rate of extravasation was 0.0022 mL/min in patients with hematoma expansion vs 0.0013 mL/min in those without (p=0.05). Conclusion: Dynamic CTA had a higher spot sign prevalence than conventional CTA. While the sensitivity in predicting expansion was higher with dCTA, the specificity was lower, possibly due to a lower risk of expansion with delayed spot signs. The rate of extravasation was roughly double in patients with hematoma expansion.

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

Stroke ◽

10.1161/str.45.suppl_1.wp257 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Farid Radmanesh ◽

Guido J Falcone ◽

Christopher D Anderson ◽

Thomas W Battey ◽

Alison M Ayres ◽

...

Keyword(s):

Logistic Regression ◽

Intracerebral Hemorrhage ◽

Ct Angiography ◽

Cerebral Amyloid Angiopathy ◽

Symptom Onset ◽

Hematoma Expansion ◽

Amyloid Angiopathy ◽

Spot Sign ◽

Increased Risk ◽

Cerebral Amyloid

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.

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Abstract WP437: The CT Angiography Spot Sign, Hematoma Expansion and Functional Outcome in Spontaneous Cerebellar ICH

Stroke ◽

10.1161/str.50.suppl_1.wp437 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Author(s):

Sanjula D Singh ◽

Bart Brouwers ◽

Floris Schreuder ◽

Andrea Morotti ◽

Marco Pasi ◽

...

Keyword(s):

Functional Outcome ◽

Ct Angiography ◽

Hematoma Expansion ◽

Spot Sign

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CT Angiography “Spot Sign” Predicts Hematoma Expansion in Acute Intracerebral Hemorrhage

Stroke ◽

10.1161/01.str.0000259633.59404.f3 ◽

2007 ◽

Vol 38 (4) ◽

pp. 1257-1262 ◽

Cited By ~ 386

Author(s):

Ryan Wada ◽

Richard I. Aviv ◽

Allan J. Fox ◽

Demetrios J. Sahlas ◽

David J. Gladstone ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Ct Angiography ◽

Hematoma Expansion ◽

Spot Sign ◽

Acute Intracerebral Hemorrhage

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Abstract 104: APOE Genotype Is Associated With CT Angiography Spot Sign In Lobar Intracerebral Hemorrhage

Stroke ◽

10.1161/str.43.suppl_1.a104 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

H. B Brouwers ◽

Alessandro Biffi ◽

Kristen A McNamara ◽

Alison M Ayres ◽

Valerie Valant ◽

...

Keyword(s):

Cohort Study ◽

Intracerebral Hemorrhage ◽

Ct Angiography ◽

Prospective Cohort Study ◽

Prospective Cohort ◽

Apoe Genotype ◽

Hematoma Expansion ◽

P Value ◽

Amyloid Angiopathy ◽

Spot Sign

Purpose: The presence of active contrast extravasation following CT angiography (CTA), the spot sign, predicts the development of hematoma expansion and poor clinical outcome in patients with primary intracerebral hemorrhage (ICH). The biological underpinnings of the spot sign remain poorly understood, and there are no established risk factors for its presence. We conducted a prospective cohort study to identify determinants of the CTA spot sign. Materials and Methods: We performed a prospective cohort study of consecutive patients presenting to a single center with primary ICH over an 11-year period. Patients were included in this analysis if they underwent CT and CTA at presentation and consented to participation in genetic studies. CTAs were reviewed by two experienced readers, blinded to clinical data, according to previously published validated criteria. Due to its established association with lobar ICH volume, APOE genotype, as well as common clinical covariates, were analyzed for association with spot sign presence. Analyses were stratified by deep, lobar and probable / definite cerebral amyloid angiopathy (CAA) related ICH (by Boston criteria). Results: Of 372 patients, 151 had deep, 198 had lobar and 23 had mixed ICH. We identified at least 1 spot sign in 96 of 372 patients (25.8%). 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, p-value 0.013) in deep ICH, OR 2.86 (95% CI 1.33-6.13, p-value 0.007) in lobar ICH and OR 6.65 (95% CI 1.34-32.99, p-value 0.020) in the subset meeting criteria for CAA-related ICH. APOE ε2, but not ε4, was associated with spot sign in lobar ICH (OR 2.09 [95% CI 1.05-4.19], p = 0.036) and CAA-related ICH (OR 2.07 [95% CI 1.24-3.46], p-value 0.005). There was no effect for ε2 or ε4 in deep ICH. ( Table 1 ) Conclusion: Patients on warfarin at the time of ICH are more likely to have a spot sign at presentation, regardless of the location of the ICH. Among patients with lobar ICH, those who possess the APOE ε2 allele are more likely to have a spot sign. Given the established relationship between APOE ε2 and vasculopathic changes in CAA, our findings suggest that both hemostatic factors and vessel pathology influence spot sign presence and risk of prolonged bleeding in ICH.

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