From Spot Sign to Bleeding on the Spot: Classic and Original Signs of Expanding Primary Spontaneous Intracerebral Hematoma

Expansion of a primary spontaneous intracranial hemorrhage (PSICH) has become lately of increasing interest, especially after the emergence of its early predictors. However, these signs lacked sensitivity and specificity. The flood phenomenon, defined as a drastic increase in the size of a PSICH during the same magnetic resonance study, was first described in this paper based on the data of a university medical center in Lebanon. Moreover, further review of this data resulted in 205 studies with presumed diagnosis of primary spontaneous intracranial hemorrhage within the last 10 years, of which 29 exams showed typical predictors of hematoma expansion on computed tomography. The intended benefit of this observation is to draw the radiologists’ attention towards minimal variations in the volume of the hematoma between the two extreme sequences of the same MRI study, in order to detect inconspicuous flood phenomena—a direct sign of hematoma expansion.

Abstract 1122‐000024: Stereotactic IntraCerebral Underwater Blood Aspiration Improves Survival Following Intracerebral Hemorrhage as Compared to Predicted Mortality

Introduction : Intracerebral hemorrhage (ICH) is a devastating form of neurological injury with substantial mortality. Recent publications on minimal invasive surgery (MIS) for hematoma evacuation have suggested survival benefits in select patients. Since 2015, our center has been performing an MIS technique using continuous irrigation with aspiration through an endoscope (SCUBA). SCUBA does not require a stability scan and can be performed despite hematoma expansion, intraventricular hemorrhage or radiographic spot sign. We present the 30‐day mortality of our initial experience and compare it to predicted mortality by presenting ICH score. Methods : We performed a retrospective review of consecutively admitted patients with spontaneous non‐traumatic supratentorial ICH who underwent SCUBA between 12/2015 – 03/2019. The primary outcome was observed 30‐day mortality compared to predicted mortality by ICH score on presentation. Key secondary outcomes were operative markers, hospital length of stay, and discharge disposition. Results : One hundred and fifteen patients were identified, with mean (SD) ICH volume of 51.4mL (33.9mL) and median ICH score of 2. The median evacuation was 97% of the hematoma volume and 85% of patients had a residual clot burden of less than 15mL. Twelve patients died within one month of SCUBA for an overall mortality rate of 10.4%. This was significantly lower than the predicted mortality by ICH score of 35.1%, with an absolute risk reduction of 24.7%. When analyzed by presenting ICH score, significant mortality benefits were observed for all ICH scores > 2, with more pronounced differences at higher ICH scores (Table 1). Conclusions : This study suggests that MIS with the SCUBA technique for ICH may reduce predicted 30‐day mortality, with a number need to treat of 4 to prevent one mortality. Further evaluation of this technique in a randomized clinical trial is required.

High-resolution CT with arch/neck/head CT angiography on a mobile stroke unit

BackgroundMobile stroke units (MSUs) performance dependability and diagnostic yield of 16-slice, ultra-fast CT with auto-injection angiography (CTA) of the aortic arch/neck/circle of Willis has not been previously reported.MethodsWe performed a prospective observational study of the first-of-its kind MSU equipped with high resolution, 16-slice CT with multiphasic CTA. Field CT/CTA was performed on all suspected stroke patients regardless of symptom severity or resolution. Performance dependability, efficiency and diagnostic yield over 365 days was quantified.Results1031 MSU emergency activations occurred; of these, 629 (61%) were disregarded with unrelated diagnoses, and 402 patients transported: 245 (61%) ischemic or hemorrhagic stroke, 17 (4%) transient ischemic attack, 140 (35%) other neurologic emergencies. Total time from non-contrast CT/CTA start to images ready for viewing was 4.0 (IQR 3.5–4.5) min. Hemorrhagic stroke totaled 24 (10%): aneurysmal subarachnoid hemorrhage 3, hemorrhagic infarct 1, and 20 intraparenchymal hemorrhages (median intracerebral hemorrhage score was 2 (IQR 1–3), 4 (20%) spot sign positive). In 221 patients with ischemic stroke, 73 (33%) received alteplase with 31.5% treated within 60 min of onset. CTA revealed large vessel occlusion in 66 patients (30%) of which 9 (14%) were extracranial; 27 (41%) underwent thrombectomy with onset to puncture time averaging 141±90 min (median 112 (IQR 90–139) min) with full emergency department (ED) bypass. No imaging needed to be repeated for image quality; all patients were triaged correctly with no inter-hospital transfer required.ConclusionsMSU use of advanced imaging including multiphasic head/neck CTA is feasible, offers high LVO yield and enables full ED bypass.

Focal Hepatic Hot Spot Sign

The focal hepatic hot spot sign appears as an area of increased radiopharmaceutical uptake of the quadrate lobe of the liver in the arteial an veinous phase. This sign seen on CT is due to obstruction of the superior vena cava and portosystemic venous shunt between the superior vena cava and the left portal vein via the thoracic and internal para-umbilical veins.

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.