Meta-Analysis of Accuracy of the Spot Sign for Predicting Hematoma Growth and Clinical Outcomes

Abstract

Background and Purpose— The computed tomography angiographic spot sign refers to contrast leakage within intracerebral hemorrhage (ICH). It has been proposed as a surrogate radiological marker for ICH growth. We conducted a meta-analysis to study the accuracy of the spot sign for predicting ICH growth and mortality. Methods— PubMed, Medline, conference proceedings, and article references in English up to June 2017 were searched for studies reporting “computed tomography angiography” and “spot sign” or “intracerebral hemorrhage” and “spot sign.” Each study was ranked on 27 criteria resulting in a quality rating score. Bivariate random effect meta-analysis was used to calculate positive and negative likelihood ratios and area under summary receiver operating characteristics curve for ICH growth and mortality. Hematoma growth was defined using the change in ≥6 mL or ≥33% increase in volume. Results— There were 26 studies describing 5085 patients, including 15 studies not used in previous meta-analyses. Positive likelihood ratio and negative likelihood ratio for ICH growth were 4.85 (95% CI, 3.85–6.02; I 2 =76.1%) and 0.49 (95% CI, 0.40–0.58) and mortality were 4.65 (95% CI, 3.67–5.90) and 0.55 (95% CI, 0.40–0.69), respectively. For ICH growth, the pooled sensitivity was 0.57 (95% CI, 0.49–0.64) and pooled false positive rate was 0.12 (95% CI, 0.09–0.14). The post-test probability of ICH growth was 0.57. The area under the curve for ICH growth and mortality was 0.86 and 0.87 (CIs are not provided in bivariate method). Meta-regression showed sensitivity of the test to decline significantly with subsequent year of publication (β=−0.148; 95% CI, −0.295 to −0.001; P =0.05). Higher quality assessment is associated with lower false positive rate (β=−0.074; 95% CI, −0.126 to −0.022; P =0.006). Conclusions— The high area under the curve potentially suggests that the spot sign can predict hematoma growth and mortality. Caution is recommended in its application given the heterogeneity across studies, which is appropriate given the data.

Dual-Energy CT Angiography Improves Accuracy of Spot Sign for Predicting Hematoma Expansion in Intracerebral Hemorrhage

“…Reported sensitivity of the SS for predicting HE ranges from 21% to 93%, with two recent meta-analyses showing a pooled sensitivity of 62% and 57% respectively. 2,4,7,[17][18][19][20][21][22][23][24][25] We found a low sensitivity of 32% of the SS on conventional-like mixed arterial phase imaging for predicting HE. While we set no limitation in the onset or LSW-toscan time in order to not exclude late expanders, many former studies only included patients with an onset-to-scan time ≤6 hours.…”

“…Two meta-analysis showed a rather low pooled sensitivity of 57% and 62% of the SS for predicting HE. 2,7 Assessment of SS on CTA might be challenging as it is difficult to differentiate hyperdense hemorrhage from contrast agent. Dual-energy CTA (DE-CTA) is a technique that uses high-and low-peak voltage acquisitions simultaneously.…”

Associations Between Levels of High-Sensitivity C-Reactive Protein and Outcome After Intracerebral Hemorrhage

“…Previous research showed that the spot sign is an independent risk factor for HE and poor clinical outcomes ( 27 – 30 ), with a sensitivity of 62% and a specificity of 88% ( 30 ). Previous studies also reported that the incidence of spot sign ranged from 19 to 46%, despite different time intervals between the onset of symptoms and initial imaging ( 15 , 29 , 31 ). In the present study, we detected the spot sign in 31.5% of our patient cohort; this incidence was similar to that reported previously.…”

The Prognostic Value of the Acute Phase Systemic Immune–Inflammation Index in Patients With Intracerebral Hemorrhage

“…Spontaneous intracerebral hemorrhage (ICH) is associated with high mortality and poor outcome ( 1 ). Studies found various indicators for predicting outcome following ICH ( 2 – 4 ); however, few of these involve biochemical tests. The brain injury after ICH includes the primary injury, which is the mechanical damage of the adjacent tissues by hematoma within the first hours after ICH, and the secondary injury, which is initiated by the extravasation of blood products into the brain parenchyma ( 5 ).…”