Swirls and spots: relationship between qualitative and quantitative hematoma heterogeneity, hematoma expansion, and the spot sign

Abstract

Background: Acute intracerebral hemorrhage (ICH) heterogeneity on NCCT, characterized by qualitative and quantitative methods, is predictive of hematoma expansion and mortality however association with the spot sign is not well-described. We sought to validate and determine the association between qualitative and quantitative hematoma heterogeneity with expansion and the spot sign, respectively. Methods: We retrospectively studied 71 ICH patients presenting <24 h post-ictus with baseline NCCT, CTA and 24-hour follow-up CT available. Baseline NCCT was assessed qualitatively for presence of swirl sign or hematoma heterogeneity by two independent readers blinded to CTA findings and quantitatively using CT densitometry (CTD). Associations with 24-hour hematoma expansion ≥6 ml or ≥33 % and spot sign were assessed using logistic regression and diagnostic performance was assessed. Association between qualitative and quantitative densitometry parameters was also examined. Results: Swirl sign and quantitative CTD standard deviation were independently associated with expansion on multivariable analysis (p = 0.037 and p = 0.032, respectively). Swirl sign and hematoma heterogeneity were predictive of CTA spot sign (p = 0.020 and p = 0.035, respectively) while CTD standard deviation demonstrated only trend univariate association. CTD parameters were not significantly associated with swirl sign while only CTD skewness was associated with hematoma heterogeneity. Agreement for swirl sign and hematoma heterogeneity identification was nearly perfect (κ = 0.81) and substantial (κ = 0.79) respectively. Conclusion: NCCT qualitative parameters predict hematoma expansion and CTA spot sign presence. Quantitative markers independently predict hematoma expansion but not CTA spot sign presence.

Noncontrast Computed Tomography Markers of Intracerebral Hemorrhage Expansion

“…7,39 Connor and colleagues retrospectively assessed the presence of density heterogeneity and spot sign in 71 patients. 39 The authors found that the presence of hypodensities was independently associated with hemorrhage-expansion but did not investigate the spatial correlation between spots and hypodense regions on NCCT. In a subanalysis of a work investigating hypodensities as a marker of hemorrhage-growth, we randomly selected 40 patients with both spot sign(s) and hypodensities.…”

Association Between Hypodensities Detected by Computed Tomography and Hematoma Expansion in Patients With Intracerebral Hemorrhage

“…20–25 Other studies have reported that an irregular shape or the heterogeneity of a hematoma (ie, the presence of a “blend sign”) can be helpful. 21,26–29 …”

Audit of CT reporting standards in cases of intracerebral haemorrhage at a comprehensive stroke centre in Australia

“…Irregular ICH shape (but not density) was found to be independently associated with poor outcome in a retrospective study of over 2000 patients . Validation studies of qualitative and quantitative densitometry measures as predictors of outcome, the presence of CTA spot sign and ICH growth have been performed in different patient cohorts . More attention to the reporting of ICH density (homogeneous/heterogeneous) and shape (regular/irregular) is recommended.…”

“…26 Validation studies of qualitative and quantitative densitometry measures as predictors of outcome, the presence of CTA spot sign and ICH growth have been performed in different patient cohorts. 25,27,35 More attention to the reporting of ICH CT angiography is being increasingly applied in the imaging assessment of acute ICH, most often in comprehensive stroke centres, particularly in patients presenting within 6 h of ictus. The CTA spot sign has been identified as an independent predictor of ICH growth and outcome 36 and is representative of dynamic haemorrhage due to the active contrast extravasation into an expanding haematoma.…”

“…Location of ICH 8,20,21 Supratentorial Infratentorial Hydrocephalus 22 Absent Present Density and shape [23][24][25][26][27] Homogeneous density, regular shape…”