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

Abstract

Objective: Patients with spontaneous intracerebral hemorrhage (ICH) presenting within 24 hours of symptom onset are known to be increased risk of hematoma expansion which is closely correlated with morbidity and mortality. We investigated whether tiny enhancing foci ('Spot sign') on axial view of 3-dimensional computed tomography angiography (3D-CTA) source images can predict subsequent hematoma expansion in spontaneous ICH.

Methods: During a 2-year period (March 2007-March 2009), we prospectively evaluated 3D-CTA of 110 patients with spontaneous ICH. Based on source images of 3D-CTA, patients were classified according to presence or absence of 'Spot sign'; 'Spot sign' (+) group, 'Spot sign' (-) group. Radiological factors and clinical outcomes were compared between two groups.

Results: Hematoma expansion occurred in 16 patients (15%). Mean Glasgow Coma Scale (GCS) score of patients with hematoma expansion was significantly different compared to score of patients without hematoma expansion (5 vs. 9, p < 0.001). Nineteen patients (16%) of 110 ICH patients demonstrated 'spot sign' on 3D-CTA. Among the 'spot sign' (+) group, 53% of patients developed hematoma expansion. Conversely 7% of patients without 'spot sign' demonstrated the hematoma expansion (p < 0.001). Initial volume and location of hematoma were significantly not associated with hematoma expansion except shape of hematoma.

Conclusion: Our study showed that patients with hematoma expansion of spontaneous ICH had significant clinical deterioration. And the fact that 'spot sign' (+) group have higher risk of hematoma expansion suggests the presence of 'spot sign' on source images of 3D-CTA can give a clue to predict hematoma expansion in spontaneous ICH.

Keywords: Computed tomography angiography; Hematoma expansion; Intracerebral hemorrhage; Prognosis.

Fig. 1

Images obtained from a 58-year-old male with a history of hypertension who presented with stupor state and left side weakness. A : Non-contrast brain computed tomography (CT) scan demonstrates spontaneous intracerebral hemorrhage (ICH) with mild surrounding edema in right basal ganglia. The patient's initial Glasgow Coma Scale (GCS) score was 9. B : Axial view in the source image of 3-dimensional computed tomography (3D-CTA) reveals that a small focus of enhancement is seen and consistent with the 'spot sign'. C : 3D-CTA shows no evidence of cerebral aneurysms or vascular malformations. D : Hematoma expansion is demonstrated on follow-up brain CT scans and the patient's GCS score was lowered to 6.

Fig. 2

Inclusive and exclusive illustrations of 'spot sign' on source images of 3-dimensional computed tomography (3D-CTA). Source images of '3D-CTA' are shown in A, B, C, D, E and corresponding schematic illustrations are shown in F, G, H, I, J. When 'spot sign' is located at the center of hematoma regardless of number (A, B), the cases included in 'spot sign' (+) group. Even though 'spot sign' (arrow) is at the periphery or within the boundary of hematoma (C), it is included in 'spot sign' (+) group. When the shape is round or ovoid (D), it is included in 'spot sign' (+) group. But the enhancing focus (E) is located out of hematoma, the focus was excluded. H : hematoma