Accuracy of the Spot Sign on Computed Tomography Angiography as a Predictor of Haematoma Enlargement after Acute Spontaneous Intracerebral Haemorrhage: A Systematic Review

Abstract

Background: A common early complication of intracerebral haemorrhage (ICH) is haematoma enlargement (HE), a strong independent predictor of a poor outcome. Therapeutic options to limit haematoma progression are currently scarce. Haemostatic therapy may be effective in patients with ICH, but it carries the risk of thromboembolic events in unselected patients. Accurate patient selection would, therefore, be of key importance for delivering potentially successful therapeutic strategies. Currently, there is no gold standard to accurately predict HE. The presence of contrast extravasation within the haematoma on computed tomography angiography (CTA), the ‘spot sign', has been reported in several studies and seems a particularly promising marker but lacks a standardised evaluation so far. Summary: We conducted a systematic review of published data to address the research question: In adults with acute spontaneous ICH, how accurately does the spot sign predict HE on follow-up imaging and thus poor functional outcome or mortality? We searched PubMed and Embase databases (from 1980 to May 2012), using a highly sensitive search strategy and including all studies involving adult patients with spontaneous ICH evaluated with CTA and follow-up CT scans, reporting any measure of clinical outcome, and reporting or allowing calculation of accuracy measures of the spot sign in predicting HE and clinical outcome. Baseline characteristics, accuracy measures and effect measures, as well as bias assessment, were reported according to PRISMA recommendations. The quality of the studies was appraised using an adapted version of the REMARK reporting recommendations. From 259 potentially relevant studies, we finally selected 6 studies (1 of them was a multicentre cohort study) covering a total of 709 patients. Studies varied substantially in terms of size, methodological quality, definitions of terms, outcomes selected and results. In particular, definition of the spot sign was not consistent in all studies. Furthermore, the only outcome measure consistently available was HE, while definitions and analyses of clinical outcomes seemed not adequate. Lastly, the choice of candidate variables for univariate and multivariate analyses did not include all determinants of HE and poor functional outcome. High heterogeneity was demonstrated (I²: 94% for HE) with substantial potential of bias. Key Messages: Studies of the spot sign are diverse and therefore complex to interpret. Our research question could not be answered due to heterogeneity and potential of bias in the selected studies. Further appropriately powered studies using standardised definitions and taking all predictors of HE and poor clinical outcome into account are required for a proper clinical implementation.

The Accuracy of Spot Sign in Predicting Hematoma Expansion after Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis

“…Then we identified 47 relevant original studies after removal of duplications. Twenty-eight studies were further excluded, involving 5 studies of secondary ICH [22] – [26] , 3 case reports [27] – [29] , 2 review article [10] , [11] , 15 studies with insufficiently detailed records of HE data [7] , [30] – [44] , and 3 studies with definition of HE contradicting with our HE criteria [45] – [47] . Then we carefully assessed studies carried out by the same institutions [9] , [48] – [53] , and data from two identical cohorts were incorporated together [48] , [49] .…”

“…Original studies on spot sign differed in population, imaging techniques, radiographic criteria, and definition of outcomes, with a wide range of predictive values. Two recent reviews have summarized the role of CTA spot sign in primary ICH [10] , [11] . However, no published report has explored the predictive accuracy of spot sign by using a meta-analytic approach.…”

Do Early Seizures Indicate Survival of Patients with Nontraumatic Intracerebral Hemorrhage?

“…We did not evaluate cortical brain microbleeds, which might serve as a predictor of ischemic brain lesions and may also represent an imaging marker of active vasculopathy [29] , or other potential prognostic values of neuroradiological biomarkers seen in susceptibility weighted imaging sequences in MRI. In a recent review, studies of the spot sign appeared diverse and therefore complex to interpret due to heterogeneity and potential of bias in the selected studies [30] . However, Havsteen et al [31] found an association between the absence or presence of a spot sign and long-term mortality and functional outcome in sICH patients.…”

Computed Tomographic Blend Sign Is Associated With Computed Tomographic Angiography Spot Sign and Predicts Secondary Neurological Deterioration After Intracerebral Hemorrhage

“…6 Another parameter predicting increasing hematoma size is the well-established spot sign (SS) visible in computed tomographic angiography (CTA). 7,8 The major advantage of the BS is the visibility in NCCT which offers a greater availability in clinical routine and a much faster and cheaper assessment. In addition, allergic reactions to contrast medium and renal dysfunction present possible contraindications for contrast application.…”