MRI spot sign: Gadolinium contrast extravasation in an expanding intracerebral hematoma on MRI

Abstract

We report a rare case of gadolinium contrast extravasation in a rapidly expanding basal ganglia hemorrhage on magnetic resonance imaging (MRI). Contrast extravasation within an intracerebral hematoma (ICH) on computed tomography (CT) angiography has been described as the “spot sign” and is a well-known indicator of active bleeding; however, contrast extravasation has seldom been reported on MRI. In this case, a 61-year-old female inpatient developed acute left hemiparesis and dysarthria on her third day of hospital admission. An initial noncontrast head CT showed an ICH, increasing in size on the follow-up CT study, and a subsequent MRI brain without and with contrast demonstrated multiple round collections of active bleeding at the margins of the hematoma on the postcontrast images. A CT angiogram performed following the MRI confirmed contrast extravasation along the margins of the hematoma. This case is unique as it demonstrates the “spot sign” with MRI, and the multiple foci of active bleeding identified with MRI support the “avalanche” hypothesis, which proposes that the initial expanding ICH leads to additional arterial ruptures and propagation of bleeding.

Acute cerebral hemorrhage mimicking glioblastoma on intraoperative magnetic resonance imaging: A case report

“…In conjunction, surgically induced enhancements on iMRI can occur in intraparenchymal spaces or at the resection margins by disrupting the blood-brain barrier [10] . Additionally, although rare, ongoing bleeding may show enhanced lesions on postenhanced T1WI by extravasation of contrast medium [11 , 12] , leading to tumor mimics as seen in the present case. As such, most neurosurgeons would be unfamiliar with hematomas showing low intensity on pre-enhanced T1WI and high intensity on postenhanced T1WI.…”

“…The preoperative MRI taken 4 days before the surgery showed no enhancement at that site; it is theoretically unlikely that the tumor grew in the 2 cm range within 4 days. On the other hand, even if the new lesion was a hematoma, these tend to increase when extravasation is observed, so it was conscientious to confirm the location of the new lesion and perform hemostasis [12] . Indeed, the new lesion was approachable with the same craniotomy in our case and we found no apparent residual tumor at the site.…”

The Magnetic Resonance Imaging “Spot” Sign: A Sign of Imminent Intracranial Hemorrhage?

“…1 Multiple case reports and studies have assessed and reported on the analogous MRI spot sign in intracerebral and subdural hematoma. [2][3][4] Our case is unique in that the "spot" sign was demonstrated incidentally on an MRI performed for a different indication prior to any symptoms or signal abnormality in the right occipital lobe. Although we cannot definitely exclude an infarct in the right occipital lobe without a DWI sequence on the initial MRI, there is breakdown of the blood-brain barrier leading to parenchymal hematoma in any case of hemorrhage, whether spontaneous hemorrhage, hemorrhagic transformation of an infarct or rupture of a mycotic aneurysm.…”