Contrast Extravasation on Computed Tomography Angiography Predicts Clinical Outcome in Primary Intracerebral Hemorrhage

Abstract

Background and Purpose-Several retrospective studies suggested that contrast extravasation on CT angiography predicts hematoma expansion, poor outcome, and mortality in primary intracerebral hemorrhage. We aimed to determine the predictive value of contrast extravasation on multidetector CT angiography for clinical outcome in a prospective study. Methods-In 160 consecutive patients with spontaneous intracerebral hemorrhage admitted within 6 hours of symptom onset, noncontrast CT and multidetector CT angiography were performed on admission. A follow-up noncontrast CT was done at 24 hours. Multidetector CT angiography images were analyzed to identify the presence of contrast extravasation. Clinical outcome was assessed by modified Rankin Scale on discharge and at 90 days. Results-A total of 139 patients with primary intracerebral hemorrhage were included in the final analysis. Contrast extravasation occurred in 30 (21.6%) patients. The presence of contrast extravasation was associated with increased hematoma expansion (PϽ0.0001), in-hospital mortality (Pϭ0.008), prolonged hospital stay (Pϭ0.006), poor outcome on discharge (Pϭ0.025), increased 3-month mortality (Pϭ0.009), and poor clinical outcome (PϽ0.0001). In multivariate analysis, contrast extravasation was a promising independent predictor (OR, 10.5; 95% CI, 3.2-34.7; PϽ0.0001) for 90-day poor clinical outcome followed by the presence of intraventricular hemorrhage (OR, 3.4; 95% CI, 1.5-7.7; Pϭ0.003) and initial hematoma volume (OR, 1.0; 95% CI, 1.0 -1.1; Pϭ0.013). Conclusions-The presence of contrast extravasation on multidetector CT angiography in patients with hyperacute-stage intracerebral hemorrhage is an independent and strong factor associated with poor outcome. Any patient with intracerebral hemorrhage with such sign on multidetector CT angiography should be monitored intensely and treated accordingly. (Stroke. 2011;42:3441-3446.)

Traumatic Intracranial Hematomas: Prognostic Value of Contrast Extravasation

“…Akin to prior nontraumatic ICH studies [12][13][14][15][16][17][18][20][21][22]38 and a smaller cerebral contusion study, 25 our results demonstrate the prognostic value of contrast extravasation in traumatic intracrananial injuries. Similarly, earlier MR imaging series evaluated "enhancement" of traumatic intra-and extra-axial hematomas, also suggesting a predictive value of extravasation in this setting but were limited by significantly smaller sample sizes.…”

“…11 In nontraumatic ICHs, contrast extravasation on CTA has been shown to predict hematoma expansion, poor outcome, and mortality. [12][13][14][15][16][17][18][19][20][21][22][23] Despite CT reports dating back Ͼ30 years identifying contrast extravasation in traumatic head injuries, 24 there has been limited analysis of this sign in the setting of trauma. A recent study evaluated 22 patients with traumatic cerebral contusions and concluded that early parenchymal CE is associated with clinical progression, cerebral edema, clinical deterioration, and the need for subsequent surgery.…”

“…In addition to the lower statistical power in the per-patient compared with the per-lesion analysis, the difference between these 2 analyses could potentially be explained by the variation in the end points: stronger prediction of total hematoma volume burden for overall poor prognosis (espe- 7,19 To ensure the clinical significance of our results, we decided to use a stricter threshold in accordance with other spontaneous and traumatic ICH studies. 8,16,50,51 In the absence of a widely accepted cutoff value for subdural hematoma and epidural hematoma expansion, the same definition was used for extra-axial hematomas.…”

Evolution of Computed Tomography Angiography Spot Sign Is Consistent With a Site of Active Hemorrhage in Acute Intracerebral Hemorrhage

“…This could in part explain the high variability in positive predictive values reported in spot sign literature (24% to 79%). 2,3,5,6 In this study, we noted that active extravasation gives rise to large irregular patterns of intrahematoma contrast that mimic the appearance of multiple spot signs when viewed in the axial plane (Figure 2; online-only Data Supplement III). The presence of multiple spot signs is a robust predictor of HE 13,14 ; the positive predictive value for significant expansion increases from 61% for 1 spot sign to 100% for ≥4 spot signs.…”

“…1 Several reports proposed the CT angiography spot sign as a radiological marker predictive of HE in the acute setting. [2][3][4][5][6] Although the general assumption is that spot sign is the radiological correlate of active bleeding at the site of vessel rupture, its exact pathology is not known. A modest positive predictive value of 61% to predict HE 6 suggests that spot sign may be present even when bleeding has ceased, perhaps representing a site of arrested hemorrhage or associated microvascular lesion such as a microaneurysm.…”