Comparison of Spot Sign, Blend Sign and Black Hole Sign for Outcome Prediction in Patients with Intracerebral Hemorrhage

Abstract

Background and Purpose Blend sign (BS) and black hole sign (BHS) on non-contrast computed tomography (NCCT) and spot sign (SS) on CT-angiography (CTA) are indicators of early hematoma expansion in spontaneous intracerebral hemorrhage (ICH). However, their independent contributions to outcome have not been well explored. Methods In this retrospective study, inclusion criteria were: 1) spontaneous ICH and 2) NCCT and CTA performed on admission within 6 hours after onset of symptoms. Discharge outcome was dichotomized as good (modified Rankin Scale [mRS] 0-3) and poor (mRS 4-6) outcomes. The impacts of BHS, BS and SS on outcome were assessed in univariate and multivariable logistic regression models. Results Of 182 patients with spontaneous ICH, 26 (14.3%) presented with BHS, 37 (20.3%) with BS and 39 (21.4%) with SS. There was a substantial correlation between SS and BS (κ=0.701) and a moderate correlation between SS and BHS (κ=0.424). In univariable logistic regression, higher baseline hematoma volume (P<0.001), intraventricular hemorrhage (P=0.002) and the presence of BHS/BS/SS (all P<0.001) on admission CT scan were associated with poor outcome. Multivariable analysis identified intraventricular haemorrhage (odds ratio [OR] 2.22 per mL, P=0.022), baseline hematoma volume (OR 1.03 per mL, P<0.001) and SS on CTA (OR 11.43, P<0.001) as independent predictors of poor outcome, showing that SS compared to BS and BHS was more powerful to predict poor outcome. Conclusions The NCCT BHS and BS are correlated with the CTA SS and are reliable predictors of poor outcome in patients with ICH. Of the CT variables indicating early hematoma expansion, SS on CTA was the most reliable outcome predictor. However, given their correlation with SS on CTA, BS and BHS on NCCT can be useful for predicting outcome if CTA is not obtainable.

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

“…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.…”

“…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. Also, a spot sign had a higher sensitivity for predicting outcome than did black hole sign in any location (34.6% vs. 23.1%) [22].…”

Radiological Predictors of Mortality in Patients With Primary Spontaneous Intracerebral Haemorrhage

“…Of the blend sign, spot sign and black hole sign, the spot sign was the most reliable outcome predictor. (35) Barras CD et al (36) have reported that heterogeneity of density within the haematoma independently predicted poor outcome. These signs however are not present in all patients and hence cannot be applied to all patients with uniformity.…”

A comparative study of the blend sign and the black hole sign on CT as a predictor of hematoma expansion in spontaneous intracerebral hemorrhage

“…The black hole sign is a relatively hypodense area within a hyperdense hematoma, with an obvious boundary adjacent to brain tissue (5). The blend sign and the black hole sign on NCCT are associated with the spot sign on CTA, and all three are predictive factors for a poor outcome in patients with sICH (11). However, no studies have compared the predictive value of the blend sign and the black hole sign on NCCT in the same cohort of patients with sICH.…”