Black Hole Sign Predicts Poor Outcome in Patients with Intracerebral Hemorrhage

Abstract

Background: In spontaneous intracerebral hemorrhage (ICH), black hole sign has been proposed as a promising imaging marker that predicts hematoma expansion in patients with ICH. The aim of our study was to investigate whether admission CT black hole sign predicts hematoma growth in patients with ICH. Methods: From July 2011 till February 2016, patients with spontaneous ICH who underwent baseline CT scan within 6 h of symptoms onset and follow-up CT scan were recruited into the study. The presence of black hole sign on admission non-enhanced CT was independently assessed by 2 readers. The functional outcome was assessed using the modified Rankin Scale (mRS) at 90 days. Univariate and multivariable logistic regression analyses were performed to assess the association between the presence of the black hole sign and functional outcome. Results: A total of 225 patients (67.6% male, mean age 60.3 years) were included in our study. Black hole sign was identified in 32 of 225 (14.2%) patients on admission CT scan. The multivariate logistic regression analysis demonstrated that age, intraventricular hemorrhage, baseline ICH volume, admission Glasgow Coma Scale score, and presence of black hole sign on baseline CT independently predict poor functional outcome at 90 days. There are significantly more patients with a poor functional outcome (defined as mRS ≥4) among patients with black hole sign than those without (84.4 vs. 32.1%, p < 0.001; OR 8.19, p = 0.001). Conclusions: The CT black hole sign independently predicts poor outcome in patients with ICH. Early identification of black hole sign is useful in prognostic stratification and may serve as a potential therapeutic target for anti-expansion clinical trials.

Prediction of Poor Outcome in Intracerebral Hemorrhage Based on Computed Tomography Markers

“…The low-density region was not completely wrapped by the high-density region [8]. The definition of black hole sign was the relatively low-density area completely surrounded by high-density hematoma; the shape of the low-density area might be different, but it was not connected with the adjacent brain tissue; the relatively low-density area had a clear edge and at least 28 Hounsfield units in the 2 densities [9].…”

“…Non-contrast CT is the first choice of conventional examination in ICH because of its fastness and convenience. Recently, non-contrast CT markers, including hypodensities [6], hematoma density [7], blend sign [8], black hole sign [9], island sign [10], and satellite sign [11], are reported to be related with poor outcome in ICH. Therefore, we aim to develop a predictive model based on these markers in an ICH cohort and validate it in another cohort.…”

New models for predicting mortality and poor prognosis after supratentorial intracerebral hemorrhage

“…Previous studies on CT signs of ICH can be roughly divided into two categories: hematoma density and hematoma shape. Li Qi et al [22] proposed that black hole sign can predict hematoma enlargement, and is related to the prognosis of dysfunction (OR,8.19;95%CI:2.44-27.49; p = 0.001) at 3 months [15] . Blend signs, liquid levels are also found to be associated with poor prognosis of ICH [20,39,40] .…”

“…The ICH volume is calculated by superimposing the area of each bleeding layer and multiplying the total area by the thickness of the section [19] . Island sign, black hole sign, blend sign, liquid level, satellite sign, hematoma irregularity and heterogeneity are identified referring to previous literatures [12][13][14][15][20][21][22] . Two experienced clinicians who were blinded to the clinical profiles of the patients independently assessed all CT signs and discrepancies were determined by an experienced professor.…”

“…Recently, some other factors were found to be associated with prognosis including hematoma enlargement, the use of antithrombotic drugs, do-not-resuscitate (DNR) treatment, intense antihypertension [9][10][11] , and newfound various CT signs (island sign, black hole sign, blend sign, hematoma irregularity and heterogeneity etc.) [12][13][14][15] . Earlier studies on the prognosis of ICH have covered a relatively simple and limited number of factors, and these models do not include newly identified CT signs, the sensitivity and specificity of the models also need to be improved.…”