Intracerebral Hematoma Morphologic Appearance on Noncontrast Computed Tomography Predicts Significant Hematoma Expansion

Abstract

Background and Purpose-Hematoma expansion in intracerebral hemorrhage is associated with higher morbidity and mortality. The computed tomography (CT) angiographic spot sign is highly predictive of expansion, but other morphological features of intracerebral hemorrhage such as fluid levels, density heterogeneity, and margin irregularity may also predict expansion, particularly in centres where CT angiography is not readily available. Methods-Baseline noncontrast CT scans from patients enrolled in the Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT (PREDICT) study were assessed for the presence of fluid levels and degree of density heterogeneity and margin irregularity using previously validated scales. Presence and grade of these metrics were correlated with the presence of hematoma expansion as defined by the PREDICT study on 24-hour followup scan. Results-Three hundred eleven patients were included in the analysis. The presence of fluid levels and increasing heterogeneity and irregularity were associated with 24-hour hematoma expansion (P=0.021, 0.003 and 0.049, respectively) as well as increases in absolute hematoma size. Fluid levels had the highest positive predictive value (50%; 28%-71%), whereas margin irregularity had the highest negative predictive value (78%; 71%-85). Noncontrast metrics had comparable predictive values as spot sign for expansion when controlled for vitamin K, antiplatelet use, and baseline National Institutes of Health Stroke Scale, although in a combined area under the receiver-operating characteristic curve model, spot sign remained the most predictive. Conclusions-Fluid levels, density heterogeneity, and margin irregularity on noncontrast CT are associated with hematoma expansion at 24 hours. These markers may assist in prediction of outcomes in scenarios where CT angiography is not readily available and may be of future help in refining the predictive value of the CT angiography spot sign. (Stroke. 2015;46:3111-3116.

Noncontrast Computed Tomography Markers of Intracerebral Hemorrhage Expansion

“…10 More recently, using the same dichotomized scale, Blacquiere and colleagues found an independent association between margin irregularity and hemorrhage-expansion with a sensitivity of 0.69 [0.59–0.78] and a specificity of 0.46 [0.40–0.53] for significant expansion in a sample of 356 patients. 26 Similarly, in a single center retrospective cohort of 1029 patients, irregular margins were found to be independently associated with hemorrhage-expansion (adjusted OR, 1.72 [95% CI, 1.07–2.76]; p = 0.02) with sensitivity and specificity of 0.66 and 0.56 respectively. 7 Finally, although these studies did not specifically investigate the impact on hemorrhage-expansion, several additional reports showed a strong association between hemorrhage margin irregularity and poor clinical outcome, potentially mediated by hemorrhage-expansion.…”

Noncontrast Computed Tomography Hypodensities Predict Poor Outcome in Intracerebral Hemorrhage Patients

“…While, numerous groups have examined the value of other NCCT markers in predicting hemorrhage expansion, 3,8,9,9,19,20 the data regarding their impact on clinical outcome, remains meager. 13 We found that of these other NCCT markers, only hemorrhage irregularity is independently associated with worse functional outcomes.…”

“…21 However, the question of whether the presence of hypodensities marks sites of active bleeding or conversely corresponds to impaired local coagulation processes remains unanswered. 8 …”

“…Other noncontrast CT markers including heterogeneity and irregularity (according to Barras et al), 12 presence of the Blend Sign (according to Li et al), 10 fluid levels (according to Blacquiere et al), 8 and of the swirl sign (According to Selariu et al) 11 were also rated independently. See supplemental Figure I at http://stroke.ahajournals.org for visual examples of each of those signs.…”

“…Several groups 8–13 have published overlapping sets of findings examining heterogeneity or irregularity of the hematoma itself. It appears that any type of hypodensity within the hematoma may mark those with ongoing bleeding, i.e.…”