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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...



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.


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.


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.

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Corresponding author

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


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