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. 2025 Mar;10(1):181-189.
doi: 10.1177/23969873241271745. Epub 2024 Aug 16.

Co-localization of NCCT hypodensity and CTA spot sign predicts substantial intracerebral hematoma expansion: The Black-&-White sign

Umberto Pensato  1   2   3 , Koji Tanaka  3 , MacKenzie Horn  3 , Ericka Teleg  3 , Abdulaziz Sulaiman Al Sultan  3   4 , Linda Kasickova  5 , Tomoyuki Ohara  6 , Piyush Ojha  3 , Sina Marzoughi  7 , Ankur Banerjee  8 , Girish Kulkarni  9 , Dar Dowlatshahi  10 , Mayank Goyal  11 , Bijoy K Menon  3   4   11 , Andrew M Demchuk  3   4   11
Affiliations

Co-localization of NCCT hypodensity and CTA spot sign predicts substantial intracerebral hematoma expansion: The Black-&-White sign

Umberto Pensato et al. Eur Stroke J. 2025 Mar.

Abstract

Background: Existing radiological markers of hematoma expansion (HE) show modest predictive accuracy. We aim to investigate a novel radiological marker that co-localizes findings from non-contrast CT (NCCT) and CT angiography (CTA) to predict HE.

Methods: Consecutive acute intracerebral hemorrhage patients admitted at Foothills Medical Centre in Calgary, Canada, were included. The Black-&-White sign was defined as any visually identified spot sign on CTA co-localized with a hypodensity sign on the corresponding NCCT. The primary outcome was hematoma expansion (⩾6 mL or ⩾33%). Secondary outcomes included absolute (<3, 3-6, 6-12, ⩾12 mL) and relative (0%, <25%, 25%-50%, 50%-75%, or >75%) hematoma growth scales.

Results: Two-hundred patients were included, with 50 (25%) experiencing HE. Forty-four (22%) showed the spot sign, 69 (34.5%) the hypodensity sign, and 14 (7%) co-localized both as the Black-&-White sign. Those with the Black-&-White sign had higher proportions of HE (100% vs 19.4%, p < 0.001), greater absolute hematoma growth (23.37 mL (IQR = 15.41-30.27) vs 0 mL (IQR = 0-2.39), p < 0.001) and relative hematoma growth (120% (IQR = 49-192) vs 0% (0-15%), p < 0.001). The Black-&-White sign had a specificity of 100% (95%CI = 97.6%-100%), a positive predictive value of 100% (95%CI = 76.8%-100%), and an overall accuracy of 82% (95%CI = 76%-87.1%). Among the 14 patients with the Black-&-White sign, 13 showed an absolute hematoma growth ⩾12 mL, and 10 experienced a HE exceeding 75% of the initial volume. The inter-rater agreement was excellent (kappa coefficient = 0.84).

Conclusion: The Black-&-White sign is a robust predictor of hematoma expansion occurrence and severity, yet further validation is needed to confirm these compelling findings.

Keywords: Hemorrhagic stroke; black and white sign; hemostatic therapy; intracranial hemorrhage; neuroimaging; radiological markers.

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Conflict of interest statement

Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Graphical abstract
Graphical abstract
Figure 1.
Figure 1.
Exemplary cases of patients with Black-&-White signs: Patient 1: a round-shaped hypodensity sign on non-contrast CT (a) with a half-moon-shaped spot sign in its inferior portion on CT angiography (b). A follow-up non-contrast CT showed a hematoma expansion of 196.51 mL (c). Patient 2: an oval-shaped hypodensity sign on non-contrast CT (d) with a comma-shaped spot sign in its superior edge on CT angiography (e). A follow-up non-contrast CT showed a hematoma expansion of 12.46 mL (f).
Figure 2.
Figure 2.
Distribution of absolute hematoma expansion across spot sign and hypodensity sign possible combinations.
Figure 3.
Figure 3.
Distribution of relative hematoma expansion across spot sign and hypodensity sign possible combinations.
See this image and copyright information in PMC

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