CT Angiography Spot Sign, Hematoma Expansion, and Outcome in Primary Pontine Intracerebral Hemorrhage

Andrea Morotti, Michael J Jessel, H Bart Brouwers, Guido J Falcone, Kristin Schwab, Alison M Ayres, Anastasia Vashkevich, Christopher D Anderson, Anand Viswanathan, Steven M Greenberg, M Edip Gurol, Javier M Romero, Jonathan Rosand, Joshua N Goldstein, Andrea Morotti, Michael J Jessel, H Bart Brouwers, Guido J Falcone, Kristin Schwab, Alison M Ayres, Anastasia Vashkevich, Christopher D Anderson, Anand Viswanathan, Steven M Greenberg, M Edip Gurol, Javier M Romero, Jonathan Rosand, Joshua N Goldstein

Abstract

Background and purpose: The computed tomography angiography (CTA) spot sign is a validated predictor of hematoma expansion and poor outcome in supratentorial intracerebral hemorrhage (ICH), but patients with brainstem ICH have typically been excluded from the analyses. We investigated the frequency of spot sign and its relationship with hematoma expansion and outcome in patients with primary pontine hemorrhage (PPH).

Methods: We performed a retrospective analysis of PPH cases obtained from a prospectively collected cohort of consecutive ICH patients who underwent CTA. CTA first-pass readings for spot sign presence were analyzed by two trained readers. Baseline and follow-up hematoma volumes on non-contrast CT scans were assessed by semi-automated computer-assisted volumetric analysis. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive and negative likelihood ratio, and accuracy of spot sign for prediction of in-hospital mortality were calculated.

Results: 49 subjects met the inclusion criteria of whom 11 (22.4 %) showed a spot sign. In-hospital mortality was higher in spot sign-positive versus spot sign-negative subjects (90.9 vs 47.4 %, p = 0.020). Spot sign showed excellent specificity (95 %) and PPV (91 %) in predicting in-hospital mortality. Absolute hematoma growth, defined as parenchymal and intraventricular hematoma expansion of any amount, was significantly higher in spot sign-positive versus spot sign-negative subjects (13.72 ± 20.93 vs 3.76 ± 8.55 mL, p = 0.045).

Conclusions: As with supratentorial ICH, the CTA spot sign is a common finding and is associated with higher risk of hematoma expansion and mortality in PPH. This marker may assist clinicians in prognostic stratification.

Keywords: Brainstem; CT angiography; Intracerebral hemorrhage; Pontine; Prognosis; Spot sign.

Conflict of interest statement

Conflict of Interest:

The authors declare that they have no conflict of interest.

Figures

Figure 1
Figure 1
A–C) Illustrative examples of spontaneous pontine hemorrhages on NCCT. B–D) Evidence of active contrast extravasation (Spot Sign) on CTA images (arrows)
Figure 2
Figure 2
A) Pontomesencephalic ICH on NCCT, with baseline volume of 29 mL. B–C) CTA showing presence of multiple spot signs (arrows). D–E–F) Follow-up NCCT at 5 hours demonstrated significant hematoma growth to a volume of 66 mL with massive intraventricular extension and hydrocephalus. The patient passed away shortly after the follow-up scan.
Figure 3
Figure 3
Log-mean absolute hematoma growth (parenchymal and intraventricular hematoma expansion). Results are presented stratified by spot sign status.
Figure 4
Figure 4
Correlation between spot sign presence and outcome (mRS) at discharge.

Source: PubMed

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