CT angiography spot sign in intracerebral hemorrhage predicts active bleeding during surgery

Abstract

Objective: To determine whether the CT angiography (CTA) spot sign marks bleeding complications during and after surgery for spontaneous intracerebral hemorrhage (ICH).

Methods: In a 2-center study of consecutive spontaneous ICH patients who underwent CTA followed by surgical hematoma evacuation, 2 experienced readers (blinded to clinical and surgical data) reviewed CTAs for spot sign presence. Blinded raters assessed active intraoperative and postoperative bleeding. The association between spot sign and active intraoperative bleeding, postoperative rebleeding, and residual ICH volumes was evaluated using univariable and multivariable logistic regression.

Results: A total of 95 patients met inclusion criteria: 44 lobar, 17 deep, 33 cerebellar, and 1 brainstem ICH; ≥1 spot sign was identified in 32 patients (34%). The spot sign was the only independent marker of active bleeding during surgery (odds ratio [OR] 3.4; 95% confidence interval [CI] 1.3-9.0). Spot sign (OR 4.1; 95% CI 1.1-17), female sex (OR 6.9; 95% CI 1.7-37), and antiplatelet use (OR 4.6; 95% CI 1.2-21) were predictive of postoperative rebleeding. Larger residual hematomas and postoperative rebleeding were associated with higher discharge case fatality (OR 3.4; 95% CI 1.1-11) and a trend toward increased case fatality at 3 months (OR 2.9; 95% CI 0.9-8.8).

Conclusions: The CTA spot sign is associated with more intraoperative bleeding, more postoperative rebleeding, and larger residual ICH volumes in patients undergoing hematoma evacuation for spontaneous ICH. The spot sign may therefore be useful to select patients for future surgical trials.

Figure 1. Case example

A 77-year-old woman had acute onset of nausea, vomiting, slurred speech, and ataxia. Her initial noncontrast CT showed a 21 mL cerebellar intracerebral hemorrhage (A). The CT angiography source images revealed 2 spot signs in the medial aspect of the hematoma (B). The postoperative CT demonstrated a fresh hematoma in the surgical bed (C). After the CT, the patient was emergently taken for repeated surgery. The patient was scored as having active intraoperative bleeding, given the extended hemostatic measures applied during the initial surgery. Given the fresh blood on the postoperative CT and the need for an additional surgical procedure, this patient was considered to have had unsuccessful hematoma removal.