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

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

Journal of Korean Neurosurgical Society ◽

10.3340/jkns.2014.56.4.295 ◽

2014 ◽

Vol 56 (4) ◽

pp. 295 ◽

Cited By ~ 6

Author(s):

Byung Hoo Moon ◽

Dong-Kyu Jang ◽

Young-Min Han ◽

Kyung-Sool Jang ◽

Ryoong Huh ◽

...

Keyword(s):

Cohort Study ◽

Intracerebral Hemorrhage ◽

Ct Angiography ◽

Spontaneous Intracerebral Hemorrhage ◽

Single Center ◽

Spot Sign ◽

Korean Patients ◽

Hematoma Growth

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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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