“Dynamic spot sign” on CT perfusion source images predicts haematoma expansion in acute intracerebral haemorrhage

Sun, Shengjun; Gao, Peiyi; Sui, Binbin; Hou, Xinyi; Yang, Lin; Xue, Jing; Zhai, Rihong

doi:10.1007/s00330-013-2803-4

Cited by 46 publications

(31 citation statements)

References 31 publications

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“…Hallevi et al 18 demonstrated that contrast extravasation on PCCT was a more sensitive predictor of hematoma expansion than the spot sign, and Ederies et al 13 demonstrated that PCCT leakage in addition to the spot sign improved sensitivity for hematoma expansion. More recent studies using dynamic CTA 17 and CTP 20,21 showed improved detection of the spot sign and increased accuracy for predicting outcome and hematoma expansion. Although it is clear that the spot sign is a dynamic finding, there is no accepted consensus regarding the timing of image acquisition.…”

Section: Discussionmentioning

confidence: 99%

Spot Sign on 90-Second Delayed Computed Tomography Angiography Improves Sensitivity for Hematoma Expansion and Mortality

Ciura

Brouwers

Pizzolato

et al. 2014

Stroke

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S pontaneous intracerebral hemorrhage (ICH) accounts for 8% to 15% of all strokes 1 and is the most fatal form of stroke, with a mortality rate of ≈50% within the first month, and 80% rate of dependency at 6 months from onset. 2 The incidence of spontaneous ICH has not changed in the past 3 decades, 3 and remains without a proven specific treatment. Several factors have been implicated as predictors of morbidity and mortality, including baseline hematoma volume, Glasgow Coma Scale score, presence of intraventricular hemorrhage, and age. [4][5][6] Independent of these factors, hematoma expansion has been described as a determinant of both mortality and functional outcome, 6,7 making attenuation of growth an attractive and potentially modifiable therapeutic target.A trial of recombinant activated factor VII (rFVIIa) generated optimism by demonstrating reduction in hematoma expansion; however, it failed to show improvement in clinical outcome and raised questions about the safety of rFVIIa given the thromboembolic complications. 8 The discrepant results may have been because of inclusion of a large number of subjects that did not expand and were therefore not likely to benefit from hemostatic therapy.Recently, the computed tomography angiography (CTA) spot sign has been validated in several studies as an imaging biomarker for hematoma expansion and poor outcome. [9][10][11][12][13][14][15] CTA spot sign has various descriptions and the outcome variables and definitions of hematoma expansion are not constant across studies, 16 the results are consistent irrespective of definition, spot sign presence reliably predicts expansion. The largest prospective study, Prediction of Haematoma Growth and Outcome in Patients With Intracerebral Haemorrhage Using the Background and Purpose-The computed tomography angiography (CTA) spot sign is a validated biomarker for poor outcome and hematoma expansion in intracerebral hemorrhage. The spot sign has proven to be a dynamic entity, with multimodal imaging proving to be of additional value. We investigated whether the addition of a 90-second delayed CTA acquisition would capture additional intracerebral hemorrhage patients with the spot sign and increase the sensitivity of the spot sign. Methods-We prospectively enrolled consecutive intracerebral hemorrhage patients undergoing first pass and 90-second delayed CTA for 18 months at a single academic center. Univariate and multivariate logistic regression were performed to assess clinical and neuroimaging covariates for relationship with hematoma expansion and mortality. Results-Sensitivity of the spot sign for hematoma expansion on first pass CTA was 55%, which increased to 64% if the spot sign was present on either CTA acquisition. In multivariate analysis the spot sign presence was associated with significant hematoma expansion: odds ratio, 17.7 (95% confidence interval, 3.7-84.2; P=0.0004), 8.3 (95% confidence interval, 2.0-33.4; P=0.004), and 12.0 (95% confidence interval, 2.9-50.5; P=0.0008) if present on first pass, delayed, or ...

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Section: Discussionmentioning

confidence: 99%

Spot Sign on 90-Second Delayed Computed Tomography Angiography Improves Sensitivity for Hematoma Expansion and Mortality

Ciura

Brouwers

Pizzolato

et al. 2014

Stroke

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“…Recently, some studies propose a ‘dynamic spot sign' using CT perfusion, a quantitative technique which allows a real-time contrast extravasation measurement. The dynamic spot sign seems to be a better prognostic marker than the CTA spot sign with higher sensitivity and predictive value [42,43,44], however, it needs to be standardised and validated.…”

Section: Discussionmentioning

confidence: 99%

Accuracy of the Spot Sign on Computed Tomography Angiography as a Predictor of Haematoma Enlargement after Acute Spontaneous Intracerebral Haemorrhage: A Systematic Review

Giudice

D'Amico²,

Sobesky

et al. 2014

Cerebrovasc Dis

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Background: A common early complication of intracerebral haemorrhage (ICH) is haematoma enlargement (HE), a strong independent predictor of a poor outcome. Therapeutic options to limit haematoma progression are currently scarce. Haemostatic therapy may be effective in patients with ICH, but it carries the risk of thromboembolic events in unselected patients. Accurate patient selection would, therefore, be of key importance for delivering potentially successful therapeutic strategies. Currently, there is no gold standard to accurately predict HE. The presence of contrast extravasation within the haematoma on computed tomography angiography (CTA), the ‘spot sign', has been reported in several studies and seems a particularly promising marker but lacks a standardised evaluation so far. Summary: We conducted a systematic review of published data to address the research question: In adults with acute spontaneous ICH, how accurately does the spot sign predict HE on follow-up imaging and thus poor functional outcome or mortality? We searched PubMed and Embase databases (from 1980 to May 2012), using a highly sensitive search strategy and including all studies involving adult patients with spontaneous ICH evaluated with CTA and follow-up CT scans, reporting any measure of clinical outcome, and reporting or allowing calculation of accuracy measures of the spot sign in predicting HE and clinical outcome. Baseline characteristics, accuracy measures and effect measures, as well as bias assessment, were reported according to PRISMA recommendations. The quality of the studies was appraised using an adapted version of the REMARK reporting recommendations. From 259 potentially relevant studies, we finally selected 6 studies (1 of them was a multicentre cohort study) covering a total of 709 patients. Studies varied substantially in terms of size, methodological quality, definitions of terms, outcomes selected and results. In particular, definition of the spot sign was not consistent in all studies. Furthermore, the only outcome measure consistently available was HE, while definitions and analyses of clinical outcomes seemed not adequate. Lastly, the choice of candidate variables for univariate and multivariate analyses did not include all determinants of HE and poor functional outcome. High heterogeneity was demonstrated (I²: 94% for HE) with substantial potential of bias. Key Messages: Studies of the spot sign are diverse and therefore complex to interpret. Our research question could not be answered due to heterogeneity and potential of bias in the selected studies. Further appropriately powered studies using standardised definitions and taking all predictors of HE and poor clinical outcome into account are required for a proper clinical implementation.

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“…The spot sign is associated with hematoma expansion and increased mortality. 35,36 In a prospective evaluation, Sun et al 37 found the spot sign to be present throughout the arterial-to-venous phases on 4D-CTA studies of 112 patients and it was an independent predictor of hematoma progression. In comparison with conventional CTA, the spot sign on 4D-CTA had a higher predictive value for hematoma expansion; therefore, 4D-CTA seems to be more accurate for estimating prognosis.…”

Section: Classification Of Arteriovenous Malformations and Arteriovenmentioning

confidence: 99%

4D-CTA in Neurovascular Disease: A Review

Kortman

Smit

Oei

et al. 2014

AJNR Am J Neuroradiol

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SUMMARY:CT angiography is a widely used technique for the noninvasive evaluation of neurovascular pathology. Because CTA is a snapshot of arterial contrast enhancement, information on flow dynamics is limited. Dynamic CTA techniques, also referred to as 4D-CTA, have become available for clinical practice in recent years. This article provides a description of 4D-CTA techniques and a review of the available literature on the application of 4D-CTA for the evaluation of intracranial vascular malformations and hemorrhagic and ischemic stroke. Most of the research performed to date consists of observational cohort studies or descriptive case series. These studies show that intracranial vascular malformations can be adequately depicted and classified by 4D-CTA, with DSA as the reference standard. In ischemic stroke, 4D-CTA better estimates thrombus burden and the presence of collateral vessels than conventional CTA. In intracranial hemorrhage, 4D-CTA improves the detection of the "spot" sign, which represents active ongoing bleeding.ABBREVIATIONS: dAVF ϭ dural arteriovenous fistula; TI-CTA ϭ timing-invariant CTA

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“Dynamic spot sign” on CT perfusion source images predicts haematoma expansion in acute intracerebral haemorrhage

Cited by 46 publications

References 31 publications

Spot Sign on 90-Second Delayed Computed Tomography Angiography Improves Sensitivity for Hematoma Expansion and Mortality

Spot Sign on 90-Second Delayed Computed Tomography Angiography Improves Sensitivity for Hematoma Expansion and Mortality

Accuracy of the Spot Sign on Computed Tomography Angiography as a Predictor of Haematoma Enlargement after Acute Spontaneous Intracerebral Haemorrhage: A Systematic Review

4D-CTA in Neurovascular Disease: A Review

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