This Article Full Text Full Text (PDF) All Versions of this Article: 40/9/2994    most recent STROKEAHA.109.554667v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Google Scholar Articles by Delgado Almandoz, J. E. Articles by Romero, J. M. PubMed PubMed Citation Articles by Delgado Almandoz, J. E. Articles by Romero, J. M. Pubmed/NCBI databases Medline Plus Health Information CT Scans Related Collections CT and MRI Acute Cerebral Hemorrhage Emergency treatment of Stroke Angiography Computerized tomography and Magnetic Resonance Imaging Intracerebral Hemorrhage

(Stroke. 2009;40:2994.)
© 2009 American Heart Association, Inc.

Original Contributions

Systematic Characterization of the Computed Tomography Angiography Spot Sign in Primary Intracerebral Hemorrhage Identifies Patients at Highest Risk for Hematoma Expansion

The Spot Sign Score

Josser E. Delgado Almandoz, MD; Albert J. Yoo, MD; Michael J. Stone, MD; Pamela W. Schaefer, MD; Joshua N. Goldstein, MD, PhD; Jonathan Rosand, MD, MSc; Alexandra Oleinik, BA; Michael H. Lev, MD; R. Gilberto Gonzalez, MD, PhD Javier M. Romero, MD

From the Division of Neuroradiology, Department of Radiology (J.E.D.A., A.J.Y., M.J.S., P.W.S., M.H.L., R.G.G., J.M.R.), the Department of Emergency Medicine (J.N.G.), and the Department of Neurology and Center for Human Genetic Research (J.R., A.O.), Massachusetts General Hospital, Harvard Medical School, Boston, Mass.

Correspondence to Josser E. Delgado Almandoz, MD, Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital Gray 2, Room 273A, 55 Fruit Street, Boston, MA 02114. E-mail josser.delgado{at}gmail.com

Background and Purpose— The presence of active contrast extravasation (the spot sign) on computed tomography (CT) angiography has been recognized as a predictor of hematoma expansion in patients with intracerebral hemorrhage. We aim to systematically characterize the spot sign to identify features that are most predictive of hematoma expansion and construct a spot sign scoring system.

Methods— We retrospectively reviewed CT angiograms performed in all patients who presented to our emergency department over a 9-year period with primary intracerebral hemorrhage and had a follow-up noncontrast head CT within 48 hours of the baseline CT angiogram. Three neuroradiologists reviewed the CT angiograms and determined the presence and characteristics of spot signs according to strict radiological criteria. Baseline and follow-up intracerebral hemorrhage volumes were determined by computer-assisted volumetric analysis.

Results— We identified spot signs in 71 of 367 CT angiograms (19%), 6 of which were delayed spot signs (8%). The presence of any spot sign increased the risk of significant hematoma expansion (69%, OR=92, P<0.0001). Among the spot sign characteristics examined, the presence of 3 spot signs, a maximum axial dimension 5 mm, and maximum attenuation 180 Hounsfield units were independent predictors of significant hematoma expansion, and these were subsequently used to construct the spot sign score. In multivariate analysis, the spot sign score was the strongest predictor of significant hematoma expansion, independent of time from ictus to CT angiogram evaluation.

Conclusion— The spot sign score predicts significant hematoma expansion in primary intracerebral hemorrhage. If validated in other data sets, it could be used to select patients for early hemostatic therapy.

Key Words: CT angiography • emergency medicine • intracerebral hemorrhage • outcome