title: 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.
abstract: OBJECTIVE
  The presence of active contrast extravasation (the spot sign) on computed tomography (CT) angiography has been recognized as a predictor of hematoma expansion in patients with intracerebral hemorrhage. We aim to systematically characterize the spot sign to identify features that are most predictive of hematoma expansion and construct a spot sign scoring system.
  
  
  METHODS
  We retrospectively reviewed CT angiograms performed in all patients who presented to our emergency department over a 9-year period with primary intracerebral hemorrhage and had a follow-up noncontrast head CT within 48 hours of the baseline CT angiogram. Three neuroradiologists reviewed the CT angiograms and determined the presence and characteristics of spot signs according to strict radiological criteria. Baseline and follow-up intracerebral hemorrhage volumes were determined by computer-assisted volumetric analysis.
  
  
  RESULTS
  We identified spot signs in 71 of 367 CT angiograms (19%), 6 of which were delayed spot signs (8%). The presence of any spot sign increased the risk of significant hematoma expansion (69%, OR=92, P<0.0001). Among the spot sign characteristics examined, the presence of > or =3 spot signs, a maximum axial dimension > or =5 mm, and maximum attenuation > or =180 Hounsfield units were independent predictors of significant hematoma expansion, and these were subsequently used to construct the spot sign score. In multivariate analysis, the spot sign score was the strongest predictor of significant hematoma expansion, independent of time from ictus to CT angiogram evaluation.
  
  
  CONCLUSIONS
  The spot sign score predicts significant hematoma expansion in primary intracerebral hemorrhage. If validated in other data sets, it could be used to select patients for early hemostatic therapy.
authors: Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA. josser.delgado@gmail.com
authors: Josser E
authors: JE
authors: Delgado Almandoz
authors: Albert J
authors: AJ
authors: Yoo
authors: Michael J
authors: MJ
authors: Stone
authors: Pamela W
authors: PW
authors: Schaefer
authors: Joshua N
authors: JN
authors: Goldstein
authors: Jonathan
authors: J
authors: Rosand
authors: Alexandra
authors: A
authors: Oleinik
authors: Michael H
authors: MH
authors: Lev
authors: R Gilberto
authors: RG
authors: Gonzalez
authors: Javier M
authors: JM
authors: Romero
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002533:Cerebral Angiography; D002543:Cerebral Hemorrhage / Q000150:complications / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000628:therapy; D002648:Child; D005260:Female; D046648:Hematoma, Subdural, Intracranial / Q000000981:diagnostic imaging* / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D014057:Tomography, X-Ray Computed