title: CTA spot sign predicts hematoma expansion in patients with delayed presentation after intracerebral hemorrhage.
abstract: BACKGROUND
  Hematoma expansion after acute intracerebral hemorrhage occurs most frequently in patients presenting within 3 h of symptom onset. However, the majority of patients present outside this window or with an unknown onset time. We investigated the prevalence of hematoma expansion in these patients and assessed the accuracy of the CT angiography (CTA) spot sign for identifying risk of hematoma expansion.
  
  
  METHODS
  We analyzed 391 consecutive patients undergoing CTA and a followup CT. CTA spot sign readings were performed by two experienced readers and hematoma expansion was assessed by means of semi-automated software.
  
  
  RESULTS
  Hematoma expansion occurred in 18 % of patients. When stratified by time from symptom onset to initial CT, hematoma expansion rates were: 39 % within 3 h; 11 % between 3 and 6 h, 11 % beyond 6 h (but with known onset), and 20 % in patients with unknown symptom onset. Of patients who developed hematoma expansion, only 38 % presented within 3 h. The accuracy of the spot sign in predicting hematoma expansion was 0.67 for patients presenting within 3 h, 0.83 between 3 and 6 h, 0.88 after 6 h, and 0.76 for patients presenting with an unknown onset time.
  
  
  CONCLUSIONS
  A substantial number of patients destined to suffer from hematoma expansion present either late or with an unknown symptom onset time. The CTA spot sign accurately identifies patients destined to expand regardless of time from symptom onset, and may therefore open a path to offer clinical trials and novel therapies to the many patients who do not present acutely.
authors.affiliation: Center for Human Genetic Research-Rosand Lab, Massachusetts General Hospital, Harvard Medical School, 185 Cambridge Street, CPZN-6818, Boston, MA 02114, USA. brouwers@chgr.mgh.harvard.edu
authors.forename: H Bart
authors.initials: HB
authors.lastname: Brouwers
authors.forename: Guido J
authors.initials: GJ
authors.lastname: Falcone
authors.forename: Kristen A
authors.initials: KA
authors.lastname: McNamara
authors.forename: Alison M
authors.initials: AM
authors.lastname: Ayres
authors.forename: Alexandra
authors.initials: A
authors.lastname: Oleinik
authors.forename: Kristin
authors.initials: K
authors.lastname: Schwab
authors.forename: Javier M
authors.initials: JM
authors.lastname: Romero
authors.forename: Anand
authors.initials: A
authors.lastname: Viswanathan
authors.forename: Steven M
authors.initials: SM
authors.lastname: Greenberg
authors.forename: Jonathan
authors.initials: J
authors.lastname: Rosand
authors.forename: Joshua N
authors.initials: JN
authors.lastname: Goldstein
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002533:Cerebral Angiography / Q000379:methods / Q000592:standards*; D002543:Cerebral Hemorrhage / Q000000981:diagnostic imaging* / Q000453:epidemiology; D057210:Delayed Diagnosis; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D015995:Prevalence; D011446:Prospective Studies; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012307:Risk Factors; D014057:Tomography, X-Ray Computed / Q000379:methods / Q000592:standards*