The Spot Sign Score in Primary Intracerebral Hemorrhage Identifies Patients at Highest Risk of In-Hospital Mortality and Poor Outcome Among Survivors

Abstract

Background and Purpose The spot sign score is a potent predictor of hematoma expansion in patients with primary intracerebral hemorrhage (ICH). We aim to determine the accuracy of this scoring system for the prediction of in-hospital mortality and poor outcome among survivors in patients with primary ICH. Methods Three neuroradiologists retrospectively reviewed CT angiograms (CTAs) performed in 573 consecutive patients who presented to our Emergency Department with primary ICH over a 9-year period to determine the presence and scoring of spot signs according to strict criteria. Baseline ICH and intraventricular hemorrhage volumes were independently determined by computer-assisted volumetric analysis. Medical records were independently reviewed for baseline clinical characteristics and modified Rankin Scale (mRS) at hospital discharge and 3-month follow-up. Poor outcome among survivors was defined as a mRS ≥4 at 3-month follow-up. Results We identified spot signs in 133 of 573 CTAs (23.2%), 11 of which were delayed spot signs (8.3%). The presence of any spot sign increased the risk of in-hospital mortality (55.6%, OR4.0, 95%CI 2.6–5.9, p<0.0001) and poor outcome among survivors at 3-month follow-up (50.8%, OR2.5, 95%CI 1.4–4.3, p 0.0014). The spot sign score successfully predicted an escalating risk of both outcome measures. In multivariate analysis, the spot sign score was an independent predictor of in-hospital mortality (OR1.5, 95%CI 1.2–1.9, p 0.0002) and poor outcome among survivors at 3-month follow-up (OR1.6, 95%CI 1.1–2.1, p 0.0065). Conclusion The spot sign score is an independent predictor of in-hospital mortality and poor outcome among survivors in primary ICH.

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.…”

CT Perfusion Spot Sign Improves Sensitivity for Prediction of Outcome Compared with CTA and Postcontrast CT

“…Prior studies have demonstrated that delayed contrast imaging detects an additional 8% of spots not seen on early imaging. [8][9][10] Furthermore, a prospective mulitcenter study using only early CTA for spot characterization demonstrated that 22% of spot-negative patients underwent hematoma expansion, 6 likely underestimating the true number of patients with contrast extravasation. A large number of potential physiologic processes may affect spot sign visualization.…”

Active extravasation of contrast within the hemorrhage (spot sign): a multidetector computed tomography finding that predicts growth and a worse prognosis in non-traumatic intracerebral hemorrhage

“…Our report has certain limitations, including the delayed arrival of the patients to our center and the smaller sample of patients relative to previous series 4,15,23,26 . Although the majority of our patients self-reported themselves as Caucasians, the incidence of miscegenation in our population is well known [10][11][12][13] .…”