The comprehensive comparison of imaging sign from CT angiography and noncontrast CT for predicting intracranial hemorrhage expansion: A comparative study

Abstract

Expansion of intracranial hemorrhage (ICH) is an important predictor of poor clinical outcomes. Various imaging markers on non-contrast computed tomography (NCCT) or computed tomographic angiography (CTA) have been reported as predictors of ICH expansion. We aimed to compare the associations between various CT imaging markers and ICH expansion. Patients with spontaneous ICH who underwent initial NCCT, CTA, and subsequent NCCT between January 2016 and December 2019 were retrospectively identified. ICH expansion was defined as a volume increase of > 33% or > 6 mL. We analyzed the presence of imaging markers such as the black hole sign, blend sign, island sign, or swirl sign on initial NCCT or spot sign on CTA. An alternative free-response receiver operating characteristic curve analysis was performed using a 4-point scoring system based on the consensus of the reviewers. The predictive value of each marker was assessed using univariate and multivariate logistic regression analyses. A total of 250 patients, including 60 (24.0%) with ICH expansion, qualified for the analysis. Among the patients with spontaneous ICH, 118 (47.2%) presented with a black hole sign, 52 (20.8%) with a blend sign, 93 (37.2%) with an island sign, 79 (31.6%) with a swirl sign, and 56 (22.4%) with a spot sign. In univariate logistic regression, the initial ICH volume (P = .038), initial intraventricular hemorrhage (IVH) presence (P < .001), swirl sign (P < .001), and spot sign (P < .001) were associated with ICH expansion. Multivariate analysis confirmed that the presence of initial IVH (odds ratio, 4.111; P = .002) and spot sign (odds ratio, 109.5; P < .001) were independent predictors of ICH expansion. Initial ICH volume, IVH, swirl sign, and spot sign are associated with ICH expansion. The presence of spot signs and IVH were independent predictors of ICH expansion.

Figure 1.

(A) Black hole sign. (B) Blend sign. (C) Island sign. (D) Swirl sign. (E) Spot sign.

Figure 2.

(A). Initial noncontrast computed tomography (CT) of a 66-year-old man demonstrates hyperdense hematoma in the left basal ganglia. Note positive findings of black hole sign, island sign, and swirl sign. (B). CT angiography demonstrates hyperdense spot signs in the hematoma (arrows). (C). Follow-up CT scan performed 2 h later demonstrates increased hematoma volume.

Figure 3.

ROC curve. The AUC of the CTA spot sign was significantly higher than that of the 4 NCCT markers. AUC = area under the ROC curves, CTA = computed tomographic angiography, NCCT = noncontrast computed tomography, ROC = receiver operating characteristic curve.