Which emphasizing factors are most predictive of hematoma expansion in spot sign positive intracerebral hemorrhage?

Abstract

Objective: The spot sign is related with the risk of hematoma expansion in spontaneous intracerebral hemorrhage (ICH). However, not all spot sign positive patients undergo hematoma expansion. Thus, the present study investigates the specific factors enhancing the spot sign positivity in predicting hematoma expansion.

Methods: We retrospectively studied 316 consecutive patients who presented between March 2009 to March 2011 with primary ICH and whose initial computed tomography brain angiography (CTA) was performed at our Emergency Department. Of these patients, 47 primary ICH patients presented spot signs in their CTA. We classified these 47 patients into two groups based on the presence of hematoma expansion then analyzed them with the following factors : gender, age, initial systolic blood pressure, history of anti-platelet therapy, volume and location of hematoma, time interval from symptom onset to initial CTA, spot sign number, axial dimension, and Hounsfield Unit (HU) of spot signs.

Results: Of the 47 spot sign positive patients, hematoma expansion occurred in 26 patients (55.3%) while the remaining 21 (44.7%) showed no expansion. The time intervals from symptom onset to initial CTA were 2.42±1.24 hours and 3.69±2.57 hours for expansion and no expansion, respectively (p=0.031). The HU of spot signs were 192.12±45.97 and 151.10±25.14 for expansion and no expansion, respectively (p=0.001).

Conclusions: The conditions of shorter time from symptom onset to initial CTA and higher HU of spot signs are the emphasizing factors for predicting hematoma expansion in spot sign positive patients.

Keywords: Hematoma expansion; Intracerebral hemorrhage; Spot sign.

Fig. 1

CT angiograms of two spot sign positive patients with and without hematoma expansion. Brain CT scans demonstrate basal ganglia hemorrhage. The upper row CT images of a 47-year-old female display hematoma expansion 2 hours after presentation with a spot sign of 3.63 mm and a density of 194 Hounsfield units (HU) (A, B, and C). The lower row CT images of a 61-year-old male show no hematoma expansion 24 hours after presentation with a spot sign of 1.21 mm and a density of 117 HU (D, E, and F).

Fig. 2

Receiver operating characteristic (ROC) curve using the Hounsfield unit (HU). The cut-off HU value was 171 [sensitivity, 65.4%; specificity, 85.7%; area under the ROC curve (AUC)=0.7919]. If the cut-off HU value was set higher than 191.0, sensitivity was 100%.