Skip to main content Accessibility help
×
Home

Defining the CT Angiography ‘Spot Sign’ in Primary Intracerebral Hemorrhage

  • Andrew L. Thompson (a1), Jayme C. Kosior (a2), David J. Gladstone (a3), Julia J. Hopyan (a3), Sean P. Symons (a1), Francisco Romero (a4), Imanuel Dzialowski (a5), Jayanta Roy (a6), Andrew M. Demchuk (a2), Richard I. Aviv (a1) and for the PREDICT/Sunnybrook ICH CTA Study Group...

Abstract

Purpose:

The computed tomogram angiography (CTA) ‘spot sign’ describes foci of intralesional enhancement associated with hematoma expansion in primary intracerebral hemorrhage patients. A consistent radiological definition is required for two proposed recombinant Factor VIIa trials planning patient dichotomization according to ‘spot sign’ presence or absence. We propose radiological criteria for diagnosis of the CTA ‘spot sign’ and describe different morphological patterns.

Material and Methods:

A prospective cohort of 36 consecutive patients presenting with primary intracerebral hemorrhage (ICH) were enrolled in a multicenter collaborative study, and have been included for the present analysis. Three reviewers analyzed the CTA studies in a blinded protocol. Analysis of specific ICH and ‘spot sign’ features was performed including prevalence, number, size, location, morphology and Hounsfield unit density.

Results:

Twelve of thirty-six patients (33%) demonstrated a total of 19 enhancing foci consistent with the CTA ‘spot sign’. Mean maximal axial ‘spot sign’ dimension was 3.7±2.2 mm and mean density was 216±57.7 HU. No significant differences in age or blood pressure (p=0.7), glucose (p=0.9), INR/PTT (p=0.3 and 0.4) or hematoma location (p=0.3) were demonstrated between patients with or without the ‘spot sign’. Consensus definition and classification criteria for the CTA ‘spot sign’ are proposed.

Conclusion:

The ‘spot sign’ is defined as spot-like and/or serpiginous foci of enhancement, within the margin of a parenchymal hematoma without connection to outside vessels. The ‘spot sign’ is greater than 1.5 mm in maximal dimension and has a Hounsfield unit density at least double that of background hematoma density.

RÉSUMÉ: Objectif :

Le spot sign à l’angiographie par tomodensitométrie (angio CT) désigne des foyers intralésionnels de rehaussement associés à une expansion de l’hématome chez les patients qui présentent une hémorragie intracérébrale primaire. Il faudra utiliser une définition radiologique fiable dans le cadre de deux essais cliniques portant sur le facteur VIIa recombinant, dans lesquels les patients seront classifiés selon la présence ou l’absence du spot sign. Nous proposons des critères radiologiques pour le diagnostic du spot sign à l’angio CT et nous décrivons différents aspects morphologiques.

Matériel et méthodes :

Une cohort prospective composée de 36 patients consécutifs qui ont consulté pour une hémorragie intracérébrale primaire (HIP) ont été inclus dans une etude multicentre effectuée en collaboration dont nous présentons les données. Trois réviseurs ont analysé les études angio CT en double insu. L’analyse de manifestations spécifiques d’HIP et de spot sign a été effectuée, dont la prévalence, le nombre, la taille, la localisation, la morphologie et la densité en unités Hounsfield (UH).

Résultats :

Au total, 19 foyers rehaussants compatibles avec un spot sign à l’angio CT ont été observés chez douze des trentesix patients (33%). La moyenne de la dimension axiale maximale du spot sign était de 3,7 ± 2,2 mm et la densité moyenne de 216 ± 57,7 UH. Aucune différence significative quant à l’âge ou à la pression sanguine (p = 0,7), la glycémie (p = 0,9), l’INR/PTT (p = 0,3 et 0,4) ou la localisation de l’hématome (p = 0,3) n’a été observée entre les patients présentant ou non le spot sign. Nous proposons une définition de consensus et des critères de classification du spot sign à l’angio CT.

Conclusion :

Le spot sign est défini comme étant des foyers de rehaussement punctiformes et/ou serpigineux à l’intérieur des marges d’un hématome parenchymateux, sans connexion aux vaisseaux extérieurs. Le spot sign a une dimension maximale de plus de 1,5 mm et une densité UH qui est au moins deux fois celle de l’hématome dans lequel il est situé.

    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Defining the CT Angiography ‘Spot Sign’ in Primary Intracerebral Hemorrhage
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Defining the CT Angiography ‘Spot Sign’ in Primary Intracerebral Hemorrhage
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Defining the CT Angiography ‘Spot Sign’ in Primary Intracerebral Hemorrhage
      Available formats
      ×

Copyright

Corresponding author

Division of Neuroradiology, Department of Medical Imaging, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada

References

Hide All
1. Broderick, JP, Adams, HP Jr, Barsan, W, Feinberg, W, Feldmann, E, Grotta, J, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 1999; 30:90515.
2. Broderick, JP, Brott, T, Tomsick, T, Huster, G, Miller, R. The risk of subarachnoid and intracerebral hemorrhages in blacks as compared with whites. N Engl J Med. 1992; 326:7336.
3. Kazui, S, Naritomi, H, Yamamoto, H, Sawada, T, Yamaguchi, T. Enlargement of spontaneous intracerebral hemorrhage. Incidence and time course. Stroke. 1996; 27:17837.
4. Kazui, S, Minematsu, K, Yamamoto, H, Sawada, T, Yamaguchi, T. Predisposing factors to enlargement of spontaneous intracerebral hematoma. Stroke. 1997; 28:23705.
5. Wada, R, Aviv, RI, Fox, AJ, Sahlas, DJ, Gladstone, DJ, Tomlinson, G, et al. CT angiography “spot sign” predicts hematoma expansion in acute intracerebral hemorrhage. Stroke. 2007; 38:125762.
6. Goldstein, JN, Fazen, LE, Snider, R, Schwab, K, Greenberg, SM, Smith, EE, et al. Contrast extravasation on CT angiography predicts hematoma expansion in intracerebral hemorrhage. Neurology. 2007; 68:88994.
7. Gazzola, S, Aviv, RI, Gladstone, DJ, Mallia, G, Li, V, Fox, AJ, et al. Vascular and non-vascular mimics of the CT angiography “spot sign” in patients with secondary intracerebral hemorrhage. Stroke. 2008; 39(4):117783.
8. Mayer, SA, Brun, NC, Begtrup, K, Broderick, J, Davis, S, Diringer, MN, et al. Recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med. 2005; 352:77785.
9. Fisher, CM. The arterial lesions underlying lacunes. Acta Neuropathol (Berl). 1968; 12:115.
10. Lammie, GA. Hypertensive cerebral small vessel disease and stroke. Brain Pathol. 2002; 12:35870.
11. Lammie, GA, Lindley, R, Keir, S, Wiggam, MI. Stress-related primary intracerebral hemorrhage: autopsy clues to underlying mechanism. Stroke. 2000; 31:14268.
12. Sutherland, GR, Auer, RN. Primary intracerebral hemorrhage. J Clin Neurosci. 2006; 13:51117.
13. Fisher, CM. Pathological observations in hypertensive cerebral hemorrhage. J Neuropathol Exp Neurol. 1971; 30:53650.
14. Cole, FM, Yates, PO. The occurrence and significance of intracerebral micro-aneurysms. J Pathol Bacteriol. 1967; 93: 393411.
15. Cole, FM, Yates, P. Intracerebral microaneurysms and small cerebrovascular lesions. Brain. 1967; 90:75968.
16. Green, F. Miliary aneurysms in the brain. J Pathol Bacteriol. 1930; 33:717.
17. Matuoka, S. Histopathological studies on the blood vessels in apoplexia. Cerebri. Proc. First International Congress of Neuropathology, Rome 1952; 3:222.
18. Fisher, CM. Cerebral miliary aneurysms in hypertension. Am J Pathol. 1972; 66:31330.
19. Charcot, JM Bouchard, C. Nouvelle recherches sur la pathogenie de l’hemorrhagie cerebrale. Arch Physiol Normale Pathol. 1868; 1:6435.
20. Fisher, CM. Hypertensive cerebral hemorrhage. Demonstration of the source of bleeding. J Neuropathol Exp Neurol. 2003; 62: 1047.

Metrics

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed