Abstract
Intracerebral hemorrhage (ICH) is one of the most devastating and costly diagnoses in the USA. ICH is a common diagnosis, accounting for 10–15 % of all strokes and affecting 20 out of 100,000 people. The CT angiography (CTA) spot sign, or contrast extravasation into the hematoma, is a reliable predictor of hematoma expansion, clinical deterioration, and increased mortality. Multiple studies have demonstrated a high negative predictive value (NPV) for ICH expansion in patients without spot sign. Our aim is to determine the absolute NPV of the spot sign and clinical characteristics of patients who had ICH expansion despite the absence of a spot sign. This information may be helpful in the development of a cost effective imaging protocol of patients with ICH. During a 3-year period, 204 patients with a CTA with primary intracerebral hemorrhage were evaluated for subsequent hematoma expansion during their hospitalization. Patients with intraventricular hemorrhage were excluded. Clinical characteristics and antithrombotic treatment on admission were noted. The number of follow-up NCCT was recorded. Of the resulting 123 patients, 108 had a negative spot sign and 7 of those patients subsequently had significant hematoma expansion, 6 of which were on antithrombotic therapy. The NPV of the CTA spot sign was calculated at 0.93. In patients without antithrombotic therapy, the NPV was 0.98. In summary, the negative predictive value of the CTA spot sign for expansion of ICH, in the absence of antithrombotic therapy and intraventricular hemorrhage (IVH) on admission, is very high. These results have the potential to redirect follow-up imaging protocols and reduce cost.
Similar content being viewed by others
Abbreviations
- ICH:
-
Intracerebral hemorrhage
- MDCTA:
-
Multidetector CT angiography
- NCCT:
-
Non-contrast computed tomography
References
Hsieh PC, Awad IA, Getch CC, Bendok BR, Rosenblatt SS, Batjer HH (2006) Current updates in perioperative management of intracerebral hemorrhage. Neurol Clin 24:745–764
Qureshi AI, Tuhrim S, Broderick JP, Batjer HH, Hondo H, Hanley DF (2001) Spontaneous intracerebral hemorrhage. N Engl J Med 344:1450–1460
Russo CA, Andrews RM. Hospital stays for stroke and other cerebrovascular diseases, 2005: Statistical brief #51. 2006
Russell MW, Joshi AV, Neumann PJ, Boulanger L, Menzin J (2006) Predictors of hospital length of stay and cost in patients with intracerebral hemorrhage. Neurology 67:1279–1281
Beinfeld MT, Gazelle GS (2005) Diagnostic imaging costs: are they driving up the costs of hospital care? Radiology 235:934–939
New choice health. www.newchoicehealth.com. Accessed October 3rd 2015.
Becker KJ, Baxter AB, Bybee HM, Tirschwell DL, Abouelsaad T, Cohen WA (1999) Extravasation of radiographic contrast is an independent predictor of death in primary intracerebral hemorrhage. Stroke 30:2025–2032
Goldstein JN, Fazen LE, Snider R, Schwab K, Greenberg SM, Smith EE, et al. (2007) Contrast extravasation on ct angiography predicts hematoma expansion in intracerebral hemorrhage. Neurology 68:889–894
Kim J, Smith A, Hemphill JC 3rd, Smith WS, Lu Y, Dillon WP, et al. (2008) Contrast extravasation on ct predicts mortality in primary intracerebral hemorrhage. AJNR Am J Neuroradiol 29:520–525
Li N, Wang Y, Wang W, Ma L, Xue J, Weissenborn K, et al. Contrast extravasation on computed tomography angiography predicts clinical outcome in primary intracerebral hemorrhage: a prospective study of 139 cases. Stroke 42:3441–3446
Wada R, Aviv RI, Fox AJ, Sahlas DJ, Gladstone DJ, Tomlinson G, et al. (2007) Ct angiography "spot sign" predicts hematoma expansion in acute intracerebral hemorrhage. Stroke 38:1257–1262
Demchuk AM, Dowlatshahi D, Rodriguez-Luna D, Molina CA, Blas YS, Dzialowski I, et al. Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the ct-angiography spot sign (predict): a prospective observational study. Lancet Neurol 11:307–314
Brouwers HB Goldstein JN. Therapeutic strategies in acute intracerebral hemorrhage. Neurotherapeutics 9:87–98
Delgado Almandoz JE, Yoo AJ, Stone MJ, Schaefer PW, Oleinik A, Brouwers HB, et al. The spot sign score in primary intracerebral hemorrhage identifies patients at highest risk of in-hospital mortality and poor outcome among survivors. Stroke 41:54–60
Romero JM, Heit JJ, Delgado Almandoz JE, Goldstein JN, Lu J, Halpern E, et al. (2012) Spot sign score predicts rapid bleeding in spontaneous intracerebral hemorrhage. Emerg Radiol 19:195–202
Brott T, Broderick J, Kothari R, Barsan W, Tomsick T, Sauerbeck L, et al. (1997) Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke 28:1–5
Delgado Almandoz JE, Yoo AJ, Stone MJ, Schaefer PW, Goldstein JN, Rosand J, et al. (2009) Systematic characterization of the computed tomography angiography spot sign in primary intracerebral hemorrhage identifies patients at highest risk for hematoma expansion: the spot sign score. Stroke 40:2994–3000
Ederies A, Demchuk A, Chia T, Gladstone DJ, Dowlatshahi D, Bendavit G, et al. (2009) Postcontrast ct extravasation is associated with hematoma expansion in cta spot negative patients. Stroke 40:1672–1676
Del Giudice A, D’Amico D, Sobesky J, Wellwood I Accuracy of the spot sign on computed tomography angiography as a predictor of haematoma enlargement after acute spontaneous intracerebral haemorrhage: a systematic review. Cerebrovasc Dis 37:268–276
Bekelis K, Fisher ES, Labropoulos N, Zhou W, Skinner J (2015) Variations in the intensive use of head ct for elderly patients with hemorrhagic stroke. Radiology 275:188–195
Koculym A, Huynh TJ, Jakubovic R, Zhang L, Aviv RI (2013) Ct perfusion spot sign improves sensitivity for prediction of outcome compared with cta and postcontrast ct. AJNR Am J Neuroradiol 34:965–970 S961
Acknowledgments
None.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Sources of fundinng
None.
Conflicts of interest
The authors declare that they have no conflict of interest.
Rights and permissions
About this article
Cite this article
Romero, J.M., Hito, R., Dejam, A. et al. Negative spot sign in primary intracerebral hemorrhage: potential impact in reducing imaging. Emerg Radiol 24, 1–6 (2017). https://doi.org/10.1007/s10140-016-1428-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10140-016-1428-8