Triage of 5 Noncontrast Computed Tomography Markers and Spot Sign for Outcome Prediction After Intracerebral Hemorrhage

Abstract

Background and Purpose— Besides the established spot sign (SS) in computed tomography angiography (CTA), there is growing evidence that different imaging markers in noncontrast CT offer great value for outcome prediction in patients with intracerebral hemorrhage (ICH). However, it is unclear how the concurrent presence of each sign independently contributes to the predictive power of poor outcome. We, therefore, aimed to clarify the predictive value of 5 recently published noncontrast CT parameters (blend sign, black hole sign, island sign, hematoma heterogeneity, and hypodensities) and the established SS in 1 consecutive series of patients with ICH. Methods— Retrospective study of patients with ICH at 2 German tertiary stroke centers; inclusion criteria were (1) spontaneous ICH and (2) noncontrast CT and CTA performed on admission within 6 hours after onset of symptoms. We defined a binary outcome (good outcome [modified Rankin Scale score of ≤3] versus poor outcome [modified Rankin Scale score of >3]) at discharge. The predictive value of each sign was assessed in univariate and multivariable logistic regression models. Results— Of 201 patients with spontaneous ICH, 28 (13.9%) presented with black hole sign, 38 (18.9%) with blend sign, 120 (59.7%) with hypodensities, 97 (48.3%) with heterogeneous densities, 53 with island sign (26.4%), and 45 (22.4%) with SS. In univariable logistic regression, higher hematoma volume ( P <0.001), intraventricular hemorrhage ( P =0.002), and the presence of black hole sign/blend sign/hypodensities/island sign/SS/heterogeneous density (all P <0.001) on admission CT were associated with poor outcome. Multivariable analysis confirmed intraventricular hemorrhage (odds ratio, 2.20; P =0.025), higher hematoma volume (odds ratio, 1.02 per mL; P <0.019), the presence of hypodensities (odds ratio, 2.47; P =0.018), and SS (odds ratio, 12.22; P <0.001) as independent predictors of poor outcome. Conclusions— This study demonstrates the degree of interaction between 5 recent noncontrast CT imaging markers and SS and their individual contribution for outcome prediction in patients with ICH. Of the CT variables indicating poor outcome SS on CTA and hypodensities were the most reliable outcome predictors.

Inter- and Intrarater Agreement of Spot Sign and Noncontrast CT Markers for Early Intracerebral Hemorrhage Expansion

“…Intracerebral hemorrhage (ICH) is the most severe form of stroke with a one month morbidity and mortality rates approaching 50% and death or severe disability exceeding 75% [1][2][3][4]. Factors reflecting the dynamic nature of hematoma evolution are particularly important for clinical outcome [5,6].…”

“…It moreover forms an appealing therapeutic target, as early hematoma expansion is potentially modifiable in the acute onset time frame [9,10]. Therefore, identification of patients with ICH and a potential risk of hematoma expansion is crucial for triage of patients and prediction of the functional outcome [1]. To this end, several imaging markers on non-contrast computed tomography (NCCT) have been described to be predictive of hematoma expansion and poor functional outcome [6].…”

Correlation between Spot Sign and Intracranial Hemorrhage Expansion on Dual-Phase CT Angiography

“…The study of Sporns et al [20] found that NCCT imaging markers were strongly correlated with an established spot sign. Taking into account that a spot sign has a higher sensitivity for outcome prediction than does a black hole sign or blend sign alone, both NCCT and CTA should be acquired if possible [20]. The results of other studies [21] have suggested that CT variables indicating early hematoma expansion, such as spot sign on CTA, are the most reliable predictors of outcome.…”

“…Subsequent papers reported the relationship between imaging findings of CTA and NCCT and ICH expansion [20][21][22]. The study of Sporns et al [20] found that NCCT imaging markers were strongly correlated with an established spot sign. Taking into account that a spot sign has a higher sensitivity for outcome prediction than does a black hole sign or blend sign alone, both NCCT and CTA should be acquired if possible [20].…”

“…Early CT protocols in patients with ICH used only NCCT or CTA after NCCT for evaluation of critical imaging findings of ICH expansion [19]. Subsequent papers reported the relationship between imaging findings of CTA and NCCT and ICH expansion [20][21][22]. The study of Sporns et al [20] found that NCCT imaging markers were strongly correlated with an established spot sign.…”