Noncontrast Computed Tomography Signs as Predictors of Hematoma Expansion, Clinical Outcome, and Response to Tranexamic Acid in Acute Intracerebral Hemorrhage

Abstract

Background and Purpose— Blend, black hole, island signs, and hypodensities are reported to predict hematoma expansion in acute intracerebral hemorrhage. We explored the value of these noncontrast computed tomography signs in predicting hematoma expansion and functional outcome in our cohort of intracerebral hemorrhage. Methods— The TICH-2 (Tranexamic acid for IntraCerebral Hemorrhage-2) was a prospective randomized controlled trial exploring the efficacy and safety of tranexamic acid in acute intracerebral hemorrhage. Baseline and 24-hour computed tomography scans of trial participants were analyzed. Hematoma expansion was defined as an increase in hematoma volume of >33% or >6 mL on 24-hour computed tomography. Poor functional outcome was defined as modified Rankin Scale of 4 to 6 at day 90. Multivariable logistic regression was performed to identify predictors of hematoma expansion and poor functional outcome. Results— Of 2325 patients recruited, 2077 (89.3%) had valid baseline and 24-hour scans. Five hundred seventy patients (27.4%) had hematoma expansion while 1259 patients (54.6%) had poor functional outcome. The prevalence of noncontrast computed tomography signs was blend sign, 366 (16.1%); black hole sign, 414 (18.2%); island sign, 200 (8.8%); and hypodensities, 701 (30.2%). Blend sign (adjusted odds ratio [aOR] 1.53 [95% CI, 1.16–2.03]; P =0.003), black hole (aOR, 2.03 [1.34–3.08]; P =0.001), and hypodensities (aOR, 2.06 [1.48–2.89]; P <0.001) were independent predictors of hematoma expansion on multivariable analysis with adjustment for covariates. Black hole sign (aOR, 1.52 [1.10–2.11]; P =0.012), hypodensities (aOR, 1.37 [1.05–1.78]; P =0.019), and island sign (aOR, 2.59 [1.21–5.55]; P =0.014) were significant predictors of poor functional outcome. Tranexamic acid reduced the risk of hematoma expansion (aOR, 0.77 [0.63–0.94]; P =0.010), but there was no significant interaction between the presence of noncontrast computed tomography signs and benefit of tranexamic acid on hematoma expansion and functional outcome ( P interaction all >0.05). Conclusions— Blend sign, black hole sign, and hypodensities predict hematoma expansion while black hole sign, hypodensities, and island signs predict poor functional outcome. Noncontrast computed tomography signs did not predict a better response to tranexamic acid. Clinical Trial Registration— URL: https://www.isrctn.com . Unique identifier: ISRCTN93732214.

Prediction of Poor Outcome in Intracerebral Hemorrhage Based on Computed Tomography Markers

“…Li et al [9] found that black hole sign could predict poor outcome in ICH. Law et al [19] demonstrated that black hole sign was a subset of hypodensities, which is consistent with our results. We also observed the overlap of black hole sign and hypodensities in this study.…”

Island Sign Predicts Hematoma Expansion and Poor Outcome After Intracerebral Hemorrhage: A Systematic Review and Meta-Analysis

“…The majority of the studies were conducted in China. Therefore, the conclusions are representative of the Chinese population at large, and similar results were not observed among Malaysians (15). The discrepancy may account, at least in part, for the diagnostic criteria.…”

“…Island sign is defined as (1) three or more scattered small hematomas all separated from the main hematoma, or (2) four or more small hematomas some or all of which may be connected with the main hematoma. Some investigations have reported that IS can predict the prognosis of ICH (11)(12)(13)(14), whereas others have reported that there was no significant correlation between IS and HE (15). There is insufficient evidence to declare that IS is an independent predictor for ICH patients' prognosis and classification.…”

Predictors and Outcomes of Neurological Deterioration in Intracerebral Hemorrhage: Results from the TICH-2 Randomized Controlled Trial

“…Measurements of hematoma, intraventricular hemorrhage and perihematomal edema (PHE) volumes were performed by three independent raters blinded to clinical data using semi-automated segmentation tools of ITK-SNAP software version 3.6.0 [ 13 , 14 ]. Radiological adjudication including location of hematoma and presence of IVH was performed by a group of qualified neuroradiologists.…”