Spot sign score is associated with hematoma expansion and longer hospital stay but not functional outcomes in primary intracerebral hemorrhage survivors.

PURPOSE: The computed tomography angiography (CTA) spot sign is a validated predictor of 30-day mortality in intracerebral hemorrhage (ICH). However, its role in predicting unfavorable functional outcomes remains unclear. This study explores the frequency of the spot sign and its association with functional outcomes, hematoma expansion, and length of hospital stay among survivors of ICH. MATERIALS AND METHODS: This was a retrospective analysis of consecutive patients with primary ICH who received CTA within 24 h of admission to two medical centers between January 2007 and August 2022. Patients who died before discharge and those referred from other hospitals were excluded. Spot signs were assessed by an experienced neuroradiologist. Functional outcomes were determined by modified Rankin Scale (mRS) scores and the Barthel Index (BI). RESULTS: In total, 98 patients were included; 14 (13.64%) had a spot sign. No significant differences were observed in the baseline characteristics between the patients with and without a spot sign. Higher spot sign scores were associated with higher odds of experiencing hematoma expansion (p = 0.013, 95% CI = 1.16-3.55), undergoing surgery (p = 0.012, 95% CI = 0.19-1.55), and having longer hospital stay (p = 0.02, 95% CI = 1.22-13.92). However, higher spot sign scores were not associated with unfavorable functional outcomes (p = 0.918 for BI, and p = 0.782 for mRS). CONCLUSION: Spot signs are common findings among patients with ICH, and higher spot sign scores were associated with subsequent hematoma expansion and longer hospital stays but not unfavorable functional outcomes.

Central retinal artery occlusion or retinal stroke: a neurosonologist's perspective.

In central retinal artery occlusion (CRAO) or retinal stroke, which is usually a vision-threatening condition, timely diagnosis is imperative to improve the chances of retinal preservation and to establish adequate secondary prevention measures. Even though retinal strokes have been traditionally assigned to the field of ophthalmology, while considering reperfusion therapy as the only way to avoid permanent vision loss, we suggest prompt evaluation of CRAO causes (primarily related to cardiovascular risk factors) performed by a well-organized interdisciplinary team (ophthalmologist and neurologist) in a neurovascular center with stroke expertise. Therefore, the most suitable adjunct method for rapidly diagnosing non-arteritic CRAO could be target transorbital ultrasound, performed by an experienced neurologist/neurosonologist in the stroke unit. Consequently, after an ophthalmological assessment, a final decision on thrombolytic therapy could be made. We accept that further research is obviously needed to determine whether transorbital ultrasound could replace ophthalmological investigation in the case of a suspected acute retinal stroke. We assert that retinal stroke requires interdisciplinary treatment in cooperation with neurologists and ophthalmologists, with an additive value for each to achieve the best results for the patient.

Predictors of severe intracerebral hemorrhage expansion.

BACKGROUND: Severe hematoma expansion (sHE) has the strongest impact on intracerebral hemorrhage (ICH) outcome. We investigated the predictors of sHE. METHODS: Retrospective analysis of ICH patients admitted at nine sites in Italy, Germany, China, and Canada. The following imaging features were analyzed: non-contrast CT (NCCT) hypodensities, heterogeneous density, blend sign, irregular shape, and CT angiography (CTA) spot sign. The outcome of interest was sHE, defined as volume increase >66% and/or >12.5 from baseline to follow-up NCCT. Predictors of sHE were explored with logistic regression. RESULTS: A total of 1472 patients were included (median age 73, 56.6% males) of whom 223 (15.2%) had sHE. Age (odds ratio (OR) per year, 95% confidence interval (CI), 1.02 (1.01-1.04)), Anticoagulant treatment (OR 3.00, 95% CI 2.09-4.31), Glasgow Coma Scale (OR 0.93, 95% CI 0.89-0.98), time from onset/last known well to imaging, (OR per h 0.96, 95% CI 0.93-0.99), and baseline ICH volume, (OR per mL 1.02, 95% CI 1.02-1.03) were independently associated with sHE. Ultra-early hematoma growth (baseline volume/baseline imaging time) was also a predictor of sHE (OR per mL/h 1.01, 95% CI 1.00-1.02). All NCCT and CTA imaging markers were also predictors of sHE. Amongst imaging features NCCT hypodensities had the highest sensitivity (0.79) whereas the CTA spot sign had the highest positive predictive value (0.51). CONCLUSIONS: sHE is common in the natural history of ICH and can be predicted with few clinical and imaging variables. These findings might inform clinical practice and future trials targeting active bleeding in ICH.

CT-based radiomics models predict spontaneous intracerebral hemorrhage expansion and are comparable with CT angiography spot sign.

Background and purpose: This study aimed to investigate the efficacy of radiomics, based on non-contrast computed tomography (NCCT) and computed tomography angiography (CTA) images, in predicting early hematoma expansion (HE) in patients with spontaneous intracerebral hemorrhage (SICH). Additionally, the predictive performance of these models was compared with that of the established CTA spot sign. Materials and methods: A retrospective analysis was conducted using CT images from 182 patients with SICH. Data from the patients were divided into a training set (145 cases) and a testing set (37 cases) using random stratified sampling. Two radiomics models were constructed by combining quantitative features extracted from NCCT images (the NCCT model) and CTA images (the CTA model) using a logistic regression (LR) classifier. Additionally, a univariate LR model based on the CTA spot sign (the spot sign model) was established. The predictive performance of the two radiomics models and the spot sign model was compared according to the area under the receiver operating characteristic (ROC) curve (AUC). Results: For the training set, the AUCs of the NCCT, CTA, and spot sign models were 0.938, 0.904, and 0.726, respectively. Both the NCCT and CTA models demonstrated superior predictive performance compared to the spot sign model (all P < 0.001), with the performance of the two radiomics models being comparable (P = 0.068). For the testing set, the AUCs of the NCCT, CTA, and spot sign models were 0.925, 0.873, and 0.720, respectively, with only the NCCT model exhibiting significantly greater predictive value than the spot sign model (P = 0.041). Conclusion: Radiomics models based on NCCT and CTA images effectively predicted HE in patients with SICH. The predictive performances of the NCCT and CTA models were similar, with the NCCT model outperforming the spot sign model. These findings suggest that this approach has the potential to reduce the need for CTA examinations, thereby reducing radiation exposure and the use of contrast agents in future practice for the purpose of predicting hematoma expansion.

Value of Image Biomarkers Based on Dual-Energy Computed Tomography Angiography Material Separation Technique in Predicting Early Hematoma Expansion in Spontaneous Intracerebral Hemorrhage.

OBJECTIVE: This study aims to investigate the connection between the leakage sign (LS) and hematoma expansion (HE) in cases of spontaneous intracerebral hemorrhage. The investigation employs dual-energy computed tomography angiography (DECTA). METHODS: A prospective cohort study was conducted, in which clinical and DECTA imaging data were collected from intracerebral hemorrhage patients within 6 hours of onset between January 2021 and June 2023. Exposure factors included DE-LS and traditional imaging biomarkers. The occurrence of HE on computed tomography rescanned within 24 hours was the observed outcome. Exposed and confounding factors were considered in both univariate and multivariate regression analyses based on the results. Logistic and adjusted Poisson regressions were employed, and odds ratios (ORs) and relative risks (RRs) were calculated with 95% confidence intervals. RESULTS: The study enrolled a total of 90 patients, of whom 32 cases manifested HE, while 58 cases did not exhibit HE. Univariate analysis revealed statistically significant differences in parameters such as admission diastolic blood pressure, C-reactive protein, Glasgow Coma Scale, baseline hematoma volume, and imaging biomarkers like DE-spot sign and DE-LS. The OR value of DE-LS was determined as 48.21, with an RR value of 7.51. Multivariate adjusted Poisson regression analysis demonstrated that DE-LS was a robust independent predictor (RR = 4.11, 95% confidence interval: 1.49-11.35; P < 0.001). CONCLUSIONS: DECTA-based DE-LS stands out as an independent predictor of HE. The utilization of RR values over OR values is endorsed when assessing the risk of HE prediction.

Venous spot sign: Indicator of rapid hematoma expansion in venous thrombosis type of submission: Case reports.

BACKGROUND: The term "spot sign" was coined by Wada et al in 2007 and thought to be due to ongoing arterial bleeding in primary intraparenchymal haemorrhage (IPH).1 Spot sign has also been described in the context of intraventricular haemorrhage (IVH).2 Over the years arterial spot signs have been found to correlate with intraparenchymal hematoma expansion, worse clinical outcomes and increased risk of surgical intervention.3 We are describing a unique instance of a spot sign in venous sinus thrombosis that initially misled the clinical diagnosis. CASE PRESENTATION: An 83-year-old woman on dual antiplatelet therapy, with a history of minor stroke, presented with sudden right-sided weakness and dysarthria. Serial CT brain imaging revealed rapidly enlarging intraparenchymal haemorrhage (IPH). Contrast enhanced CT displayed multiple spot signs typically associated with arterial bleeding pattern. Initially possibility of antithrombotic related IPH was kept, however venogram confirmed venous pathology with focal superior sagittal sinus thrombosis (SSS). Unfortunately, the patient deteriorated and eventually succumbed to the illness before the diagnosis could be made. CONCLUSION: The case exemplifies the potential of venous sinus thrombosis to manifest as a spot sign, thereby emphasizing the need for a broader differential diagnosis. The rarity of venous spot signs may be attributed to patient-specific venous anatomy and poor collateralization in the occluded sinus territory.

Pseudoaneurysm as a differential for the computed tomography angiography "spot sign" in atypical presentations of intracerebral hemorrhage: illustrative case.

BACKGROUND: The computed tomography angiography (CTA) "spot sign" is a well-recognized radiographic marker in primary intracerebral hemorrhage (ICH). Although it has been demonstrated to represent an area of active hemorrhage or contrast extravasation, the exact pathophysiology remains unclear. Vascular mimics of the spot sign have been identified; however, those representing pseudoaneurysm and small vessel aneurysm have rarely been reported. OBSERVATIONS: A 57-year-old female with a past medical history of hypertension and diabetes mellitus presented with 2 weeks of acute-onset, worsening headache. Computed tomography scanning showed a right interior frontal lobe intraparenchymal hemorrhage. CTA demonstrated a punctate focus of hyperattenuation within the hematoma, consistent with a spot sign, which corresponded to a distal anterior cerebral artery pseudoaneurysm on a cerebral angiogram. The patient subsequently underwent emergent resection of the pseudoaneurysm and hematoma evacuation without complications. Her postoperative course was unremarkable without acute concerns or residual symptoms at the 4-month follow-up. LESSONS: The authors present a unique case of a distal anterior cerebral artery pseudoaneurysm presenting as a spot sign in a relatively young patient without underlying vascular disease. Given the need for emergent intervention, intracranial pseudoaneurysm is an important diagnosis to consider in the presence of a spot sign in atypical clinical presentations of primary ICH.

Intraoperative imaging reveals spot sign with surgical correlate during early endoscopic ICH evacuation.

Intracerebral hemorrhage (ICH) is the most devastating form of stroke. Intraoperative imaging and management of intracavity bleeding during early endoscopic ICH evacuation may mitigate rebleeding, hematoma expansion, and neurological worsening. Here we document a case of intraoperative spot sign, detected in the angio suite using cone beam CT with contrast protocol, in a patient with spontaneous supratentorial ICH undergoing evacuation 13 hours after last known well. The spot sign was detected after endoscopic evaluation of the evacuated hematoma cavity demonstrated sufficient hemostasis, but before completion of the case and skin closure, prompting second-pass hematoma evacuation as well as identification and cauterization of the specific correlating bleeding vessel, resulting in near-complete evacuation of the hematoma. Spot sign detection on intraoperative cone beam CT followed by endoscopic ICH evacuation may provide an opportunity to specifically target and treat active bleeding and mitigate impending expansion and neurologic worsening, especially in high-risk patients, including those undergoing early ICH evacuation.

Intracerebral hemorrhage markers on non-contrast computed tomography as predictors of the dynamic spot sign on CT perfusion and associations with hematoma expansion and outcome.

PURPOSE: To assess the association between non-contrast computed tomography (NCCT) hematoma markers and the dynamic spot sign on computed tomography perfusion (CTP), and their associations with hematoma expansion, clinical outcome, and in-hospital mortality. METHODS: Patients who presented with intracerebral hemorrhage (ICH) to a stroke center over an 18-month period and underwent baseline NCCT and CTP, and a follow-up NCCT within 24 h after the baseline scan were included. The initial and follow-up hematoma volumes were calculated. Two raters independently assessed the baseline NCCT for hematoma markers and concurrently assessed the CTP for the dynamic spot sign. Univariate and multivariate logistic regression analyses were performed to assess the association between the hematoma markers and the dynamic spot sign, adjusting for known ICH expansion predictors. RESULTS: Eighty-five patients were included in our study and 55 patients were suitable for expansion analysis. Heterogeneous density was the only NCCT hematoma marker to be associated with the dynamic spot sign after multivariate analysis (odds ratio, 58.61; 95% confidence interval, 9.13-376.05; P < 0.001). The dynamic spot sign was present in 22 patients (26%) and significantly predicted hematoma expansion (odds ratio, 36.6; 95% confidence interval, 2.51-534.2; P = 0.008). All patients with a spot sign had a swirl sign. A co-located hypodensity and spot sign was significantly associated with in-hospital mortality (odds ratio, 6.17; 95% confidence interval, 1.09-34.78; P = 0.039). CONCLUSION: Heterogeneous density and swirl sign are associated with the dynamic spot sign. The dynamic spot sign is a stronger predictor than NCCT hematoma markers of significant hematoma expansion. A co-located spot sign and hypodensity predicts in-hospital mortality.

The Spot Sign and Intraventricular Hemorrhage are Associated with Baseline Coagulopathy and Outcome in Intracerebral Hemorrhage.

BACKGROUND: Spontaneous intracerebral hemorrhage (ICH) is the second most prevalent subtype of stroke and has high mortality and morbidity. The utility of radiographic features to predict secondary brain injury related to hematoma expansion (HE) or increased intracranial pressure has been highlighted in patients with ICH, including the computed tomographic angiography (CTA) spot sign and intraventricular hemorrhage (IVH). Understanding the pathophysiology of spot sign and IVH may help identify optimal therapeutic strategies. We examined factors related to the spot sign and IVH, including coagulation status, hematoma size, and location, and evaluated their prognostic value in patients with ICH. METHODS: Prospectively collected data from a single center between 2012 and 2015 were analyzed. Patients who underwent thromboelastography within 24 h of symptom onset and completed follow-up brain imaging and CTA within 48 h after onset were included for analysis. Multivariate logistic regression analyses were performed to identify determinants of the spot sign and IVH and their predictive value for HE, early neurological deterioration (END), in-hospital mortality, and functional outcome at discharge. RESULTS: Of 161 patients, 50 (31.1%) had a spot sign and 93 (57.8%) had IVH. In multivariable analysis, the spot sign was associated with greater hematoma volume (odds ratio [OR] 1.02; 95% confidence interval [CI] 1.00-1.03), decreased white blood cell count (OR 0.88; 95% CI 0.79-0.98), and prolonged activated partial thromboplastin time (OR 1.14; 95% CI 1.06-1.23). IVH was associated with greater hematoma volume (OR 1.02; 95% CI 1.01-1.04) and nonlobar location of hematoma (OR 0.23; 95% CI 0.09-0.61). The spot sign was associated with greater risk of all adverse outcomes. IVH was associated with an increased risk of END and reduced HE, without significant impact on mortality or functional outcome. CONCLUSIONS: The spot sign and IVH are associated with specific hematoma characteristics, such as size and location, but are related differently to coagulation status and clinical course. A combined analysis of the spot sign and IVH can improve the understanding of pathophysiology and risk stratification after ICH.

Contribution of Orbital Ultrasound to the Diagnosis of Central Retinal Artery Occlusion.

We aimed to evaluate the diagnostic value of orbital ultrasound in the etiologic diagnosis of central retinal artery occlusion (CRAO). For this purpose, patients with CRAO evaluated at our center between 2011 and 2021 were reviewed. Demographic variables, vascular risk factors and ultrasound findings were collected. An orbital duplex was performed in all cases and complemented with other diagnostic explorations. We attended 36 cases of CRAO. In all patients, orbital ultrasound confirmed the diagnosis of CRAO: in 75% emboli material (spot sign) was observed in CRA and in 25% flow alteration in CRA without visible embolus. The positive spot sign (PSS) group differed from patients with negative spot sign (NSS) in terms of etiology: 8 PSS cases (29.6%) had a major cardioembolic cause, 4 (14.8%) a large vessel atheromatous disease, 15 (55.6%) an undetermined cause. Some 21 (77.8%) PSS patients had some minor cardioembolic cause, mainly calcifications of the left valves. In the NSS group, 2 (22%) were diagnosed with giant cell arteritis (GCA). In CRAO, the ultrasound spot sign could be a guide for the detection of embolic sources. Its absence makes it necessary to consider more strongly the possibility of arteritis. Furthermore, our findings suggest a key role of calcium embolism in PSS patients.

Does tranexamic acid affect intraventricular hemorrhage growth in acute ICH? An analysis of the STOP-AUST trial.

Background: Trials of tranexamic acid (TXA) in acute intracerebral hemorrhage (ICH) have focused on the imaging outcomes of intraparenchymal hematoma growth. However, intraventricular hemorrhage (IVH) growth is also strongly associated with outcome after ICH. Revised definitions of hematoma expansion incorporating IVH growth have been proposed. Aims: We sought to evaluate the effect of TXA on IVH growth. Methods: We analyzed data from the STOP-AUST trial, a prospective randomized trial comparing TXA to placebo in ICH patients presenting ≤ 4.5 h from symptom onset with a CT-angiography spot sign. New IVH development at follow-up, any interval IVH growth, and IVH growth ≥ 1 mL were compared between the treatment groups using logistic regression. The treatment effect of TXA against placebo using conventional (> 6 mL or 33%), and revised definitions of hematoma expansion (> 6 mL or 33% or IVH expansion ≥ 1 mL, > 6 mL or 33%, or any IVH expansion, and > 6 mL or 33% or new IVH development) were also assessed. Treatment effects were adjusted for baseline ICH volume. Results: The analysis population consisted of 99 patients (50 placebo, 49 TXA). New IVH development at follow-up was observed in 6/49 (12%) who received TXA and 13/50 (26%) who received placebo (aOR: 0.38 [95% CI: 0.13-1.13]). Any interval IVH growth was observed in 12/49 (25%) who received TXA versus 26/50 (32%) receiving placebo (aOR: 0.69 [95% CI: 0.28-1.66]). IVH growth ≥ 1 mL did not differ between the two groups. Using revised definitions of hematoma expansion, no significant difference in treatment effect was observed between TXA and placebo. Conclusions: IVH may be attenuated by TXA following ICH; however, studies with larger cohorts are required to investigate this further. Registration: http://www.clinicaltrials.gov; Unique identifier: NCT01702636.

The Predictive Accuracy of the Delayed Spot Sign for Haematoma Expansion in Spontaneous Supratentorial Intracerebral Haemorrhage: A Systematic Review and Meta-Analysis.

Previous studies have shown that spot signs on imaging modalities such as CT perfusion, delayed phase CTA or post contrast CT imaging reportedly have greater ability to predict haematoma expansion (HE) than the traditional CT angiography spot sign. We performed a systematic review and meta-analysis of the diagnostic accuracy of the spot sign on delayed imaging modalities in predicting haematoma expansion. Pubmed, Excerpta Medica Database, and the Cochrane library were searched on the 11 November 2019. The search strategy utilised the following terms: CT angiography OR post contrast CT OR CT perfusion OR CT AND intracerebral haemorrhage (or synonyms) AND spot sign OR delayed spot sign OR dynamic spot sign. The area under the summary of receiver operating curves for diagnostic accuracy of delayed spot sign in predicting HE was calculated using bivariate random effects meta-analysis. 501 articles were identified, with 10 meeting inclusion criteria. The studies included 711 patients overall, with 272 (38%) demonstrating a spot sign. The presence of a delayed spot sign was associated with HE with a diagnostic odds ratio of 25.4 (12.7-50.9). Pooled sensitivity was 0.81 (0.72-0.88), with a pooled specificity of 0.82 (0.76-0.88). Pooled positive likelihood ratio was 4.30, with a pooled negative likelihood ratio of 0.26. The area under the receiver operating curve (AUC) was 0.88. The delayed spot sign has greater diagnostic accuracy in predicting haematoma expansion than the traditional CT angiography spot sign. Further research could determine the delayed imaging technique that has the greatest diagnostic accuracy.

Predictive Ability of Ultraearly Hematoma Growth and Spot Sign for Redefined Hematoma Expansion in Patients with Spontaneous Intracerebral Hemorrhage.

BACKGROUND: Redefined hematoma expansion (rHE) including intraventricular hematoma expansion (IVHE) is a new concept in intracerebral hemorrhage (ICH), with better prognostic ability compared to the conventional hematoma expansion. Ultraearly hematoma growth (uHG) and computed tomography angiography (CTA) spot sign are both useful indictors to predict HE and poor clinical outcome. This study aims to explore the clinical characteristics of rHE in retrospective cohort and evaluate the predictive ability of uHG and spot sign in rHE. MATERIALS AND METHODS: This study included nontraumatic spontaneous ICH patients from June 1st 2013 and January 1st 2018 in West China Hospital. Multivariate logistic regression was used to determine risk factors for HE/IVHE/rHE and primary outcomes of ICH patients. Receiver operating characteristic (ROC) analysis was performed to assess the accuracy of uHG and spot sign for predicting HE/IVHE/rHE. RESULTS: This retrospective cohort included 469 consecutive patients with ICH. rHE was significantly associated with clinical variables including Glasgow coma scale (GCS), time to initial CT, presence of IVH, hematoma volume, presence of spot sign, and uHG. uHG and spot sign were independent risk factors for rHE. ROC analysis indicated that both uHG (AUC 0.726, 95%CI 0.680-0.773) and spot sign (AUC 0.735, 95%CI 0.686-0.785) possessed high predictive accuracy for rHE. HE and rHE were independent risk factors for 1-month mortality and 3-month functional outcome. CONCLUSIONS: Both uHG and the spot sign were considered to be good predictors for rHE, and the spot sign appeared to have a better predictive accuracy.

Neuroimaging of Acute Intracerebral Hemorrhage.

Intracerebral hemorrhage (ICH) accounts for 10% to 20% of all strokes worldwide and is associated with high morbidity and mortality. Neuroimaging is clinically important for the rapid diagnosis of ICH and underlying etiologies, but also for identification of ICH expansion, often as-sociated with an increased risk for poor outcome. In this context, rapid assessment of early hema-toma expansion risk is both an opportunity for therapeutic intervention and a potential hazard for hematoma evacuation surgery. In this review, we provide an overview of the current literature surrounding the use of multimodal neuroimaging of ICH for etiological diagnosis, prediction of early hematoma expansion, and prognostication of neurological outcome. Specifically, we discuss standard imaging using computed tomography, the value of different vascular imaging modalities to identify underlying causes and present recent advances in magnetic resonance imaging and computed tomography perfusion.

Early spot sign is associated with functional outcomes in primary intracerebral hemorrhage survivors.

BACKGROUND: The computed tomography angiography (CTA) spot sign is a validated predictor of hematoma expansion and 30-day mortality in intracerebral hemorrhage (ICH). However, whether the spot sign predicts worse functional outcomes among ICH survivors remains unclear. This study investigated the frequency of the spot sign and its association with functional outcomes and length of hospital stay among ICH survivors. METHODS: This was a retrospective analysis of consecutive patients with primary ICH who received CTA within 24 h from presentation to admission to the emergency department of a single medical center between January 2007 and December 2017. Patients who died before discharge and those referred from other hospitals were excluded. CTAs with motion artifacts were excluded from the analysis. The presence of a spot sign was examined by an experienced neuroradiologist. Functional outcomes were determined based on the modified Rankin Scale (mRS) score and Barthel Index (BI). Severe dependency in activities of daily living (ADL) was defined as BI of ≤60 and severe disability as an mRS score of ≥4. Odds ratio (OR) and multiple linear regression were used as measures of association. RESULTS: In total, 66 patients met the inclusion criteria, of whom 9 (13.64%) were positive for a spot sign. No significant differences were observed in baseline characteristics between patients with and without a spot sign. Patients with a spot sign tended to be severely dependent in ADL at discharge (66.67% vs 41.07%; OR = 2.87; p = 0.15) and were more likely to require ICH-related surgery (66.67% vs 24.56%; OR = 6.14; p = 0.01). In multiple linear regression, patients with a higher spot sign score had a significantly longer hospital stay (coefficient = 9.57; 95% CI = 2.11-17.03; p = 0.013). CONCLUSIONS: The presence of a spot sign is a common finding and is associated with longer hospital stay and possibly worse functional outcomes in ICH survivors.

Is the detectability of the spot sign on CT angiography depending on slice thickness and reconstruction type?

OBJECTIVE: The spot sign is a validated imaging marker widely used in CT angiography (CTA) to detect active bleeding and a higher risk of hematoma expansion in patients with intracerebral hemorrhage (ICH). The aim of this study was to investigate the detectability of spot signs on thin multiplanar projection reconstruction (MPR) images compared to thicker maximum intensity projection (MIP) images. METHODS: In this retrospective analysis, we assessed imaging data of 146 patients with primary hypertensive/microangiopathic ICH who received emergency non-contrast computed tomography (NCCT) and CTA. Two experienced radiologists, blinded to each other, evaluated images of thin (1 mm) MPR images and thick (3 mm) MIP images on the presence of spot signs and performed a consensus reading. Kappa tests were used for data comparison. RESULTS: In total, spot signs were observed in 27 cases (=18.5 %) in both thin MPR and thick MIP slices. Detectability of the spot sign did not differ in 1 mm MPR images and 3 mm MIP images (Cohen's kappa, 1.0; p = 0.00). Also, when the readings of the two radiologists were analyzed separately, results for MPR and MIP slices were similar (MPR: Cohen's kappa, 0.81, p = 0.00; MIP: Cohen's kappa, 0.74; p = 0.00). CONCLUSION: No significant difference in the detectability of the spot sign could be demonstrated when comparing 1 mm MPR images with 3 mm MIP images.

Dual-Energy CT Angiography Improves Accuracy of Spot Sign for Predicting Hematoma Expansion in Intracerebral Hemorrhage.

BACKGROUND AND PURPOSE: Spot sign (SS) on computed tomography angiography (CTA) is associated with hematoma expansion (HE) and poor outcome after intracerebral hemorrhage (ICH). However, its predictive performance varies across studies, possibly because differentiating hyperdense hemorrhage from contrast media is difficult. We investigated whether dual-energy-CTA (DE-CTA), which can separate hemorrhage from iodinated contrast, improves the diagnostic accuracy of SS for predicting HE. METHODS: Primary ICH patients undergoing DE-CTA (both arterial as well as delayed venous phase) and follow-up computed tomography were prospectively included between 2014 and 2019. SS was assessed on both arterial and delayed phase images of the different DE-CTA datasets, i.e., conventional-like mixed images, iodine images, and fusion images. Diagnostic accuracy of SS for prediction of HE was determined on all datasets. The association between SS and HE, and between SS and poor outcome (modified Rankin Scale at 3 months ≥3) was assessed with multivariable logistic regression, using the dataset with highest diagnostic accuracy. RESULTS: Of 139 included patients, 47 showed HE (33.8%). Sensitivity of SS for HE was 32% (accuracy 0.72) on conventional-like mixed arterial images which increased to 76% (accuracy 0.80) on delayed fusion images. Presence of SS on delayed fusion images was independently associated with HE (odds ratio [OR], 17.5; 95% confidence interval [CI], 6.14 to 49.82) and poor outcome (OR, 3.84; 95% CI, 1.16 to 12.73). CONCLUSIONS: Presence of SS on DE-CTA, in particular on delayed phase fusion images, demonstrates higher diagnostic performance in predicting HE compared to conventional-like mixed imaging, and it is associated with poor outcome.

Different criteria for defining "spot sign" in intracerebral hemorrhage show different abilities to predict hematoma expansion and clinical outcomes: a systematic review and meta-analysis.

The "spot sign" is a well-known radiological marker used for predicting hematoma expansion and clinical outcomes in patients with intracerebral hemorrhage (ICH). We performed a meta-analysis to assess the predictive accuracy of spot sign, depending on the criteria used to identify them.We conducted a systematic review of clinical studies that clearly stated their definition of spot sign and that were indexed in the Cochrane Library, MEDLINE, EMBASE, and the China National Knowledge Infrastructure databases. We collected data on computed tomography (CT) parameters, spot sign diagnostic criteria, hematoma expansion, and clinical outcomes.Based on the eligibility criteria, we included 17 studies in this systematic review. CT imaging modality, type, time from symptom onset to CT, time from contrast infusion to scan, slice thickness, tube current, and tube electric discharge showed variation across studies. Three different definitions of the spot sign were applied: (1) a hyperdense spot within the hematoma; (2) one or more focal areas/regions of contrast pooling of any size and morphology that occurred within a hemorrhage, were discontinuous from the normal or abnormal vasculature adjacent to the hemorrhage, and showed an attenuation rate ≥ 120 UH; or (3) serpiginous or spot-like contrast density on CTA images that occurred within the hematoma margin, showed twice the density of the hematoma background, and did not contact vessels outside the hematoma. Three definitions for the spot sign were identified, all of which were associated with hematoma expansion, mortality, and unfavorable functional outcome. Subgroup analyses based on these definitions showed that spot sign identified using the second definition were more likely to be associated with hematoma expansion (OR 18.31, 95% CI 9.11-36.8) and unfavorable functional outcomes (OR 8.78, 95% CI 3.24-23.79), while those identified using the third definition were associated with increased risk of mortality (OR 6.88, 95% CI 1.43-33.13).Clinical studies identify spot sign using different CT protocols and criteria. These differences affect the ability of spot sign to predict hematoma expansion and clinical outcomes in ICH patients.

Eliminating vascular interference from the Spot Sign contributes to predicting hematoma expansion in individuals with spontaneous cerebral hemorrhages.

The computed tomography angiography (CTA) Spot Sign is an effective means of predicting hematoma expansion (HE) in the context of spontaneous intracerebral hemorrhage (ICH). We investigated whether continuous CTA source images could differentiate the Spot Sign and blood vessels in the hematoma, and whether it would improve Spot Sign accuracy as an HE predictor. We screened for the presence of CTA Spot Sign in individuals affected by spontaneous ICH within 24 h of symptom development. Based on our findings, we determined the sensitivity, specificity, and positive/negative predictive values of this sign as a predictor of HE both on its own and following the exclusion of blood vessels. In addition, a receiver-operating characteristic approach was used to assess the accuracy of Spot Sign with and without elimination of vascular interference. A total of 265 patients were included in this study. The Spot Sign was observed in 100 patients, including in 29 patients wherein it was confirmed to be blood vessels as determined based upon continuous CTA source images. With respect to predicting HE, Spot Sign sensitivity, specificity, positive predictive values, and negative predictive values were 57%, 71%, 48% and 78%, respectively. Following the exclusion of blood vessels, these values were 57%, 87%, 68% and 81%, respectively. Spot Sign area under the curve after excluding blood vessels was 0.718, which was higher than that of the Spot Sign (0.638). After continuous CTA, source images are used to exclude blood vessels in the hematoma, the Spot Sign is thus more accurate in predicting HE.