title: CT angiography spot sign in intracerebral hemorrhage predicts active bleeding during surgery.
abstract: OBJECTIVE
  To determine whether the CT angiography (CTA) spot sign marks bleeding complications during and after surgery for spontaneous intracerebral hemorrhage (ICH).
  
  
  METHODS
  In a 2-center study of consecutive spontaneous ICH patients who underwent CTA followed by surgical hematoma evacuation, 2 experienced readers (blinded to clinical and surgical data) reviewed CTAs for spot sign presence. Blinded raters assessed active intraoperative and postoperative bleeding. The association between spot sign and active intraoperative bleeding, postoperative rebleeding, and residual ICH volumes was evaluated using univariable and multivariable logistic regression.
  
  
  RESULTS
  A total of 95 patients met inclusion criteria: 44 lobar, 17 deep, 33 cerebellar, and 1 brainstem ICH; ≥1 spot sign was identified in 32 patients (34%). The spot sign was the only independent marker of active bleeding during surgery (odds ratio [OR] 3.4; 95% confidence interval [CI] 1.3-9.0). Spot sign (OR 4.1; 95% CI 1.1-17), female sex (OR 6.9; 95% CI 1.7-37), and antiplatelet use (OR 4.6; 95% CI 1.2-21) were predictive of postoperative rebleeding. Larger residual hematomas and postoperative rebleeding were associated with higher discharge case fatality (OR 3.4; 95% CI 1.1-11) and a trend toward increased case fatality at 3 months (OR 2.9; 95% CI 0.9-8.8).
  
  
  CONCLUSIONS
  The CTA spot sign is associated with more intraoperative bleeding, more postoperative rebleeding, and larger residual ICH volumes in patients undergoing hematoma evacuation for spontaneous ICH. The spot sign may therefore be useful to select patients for future surgical trials.
authors.affiliation: From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands. H.B.Brouwers-4@umcutrecht.nl.
authors.forename: H Bart
authors.initials: HB
authors.lastname: Brouwers
authors.affiliation: From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands.
authors.forename: Miriam R
authors.initials: MR
authors.lastname: Raffeld
authors.affiliation: From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands.
authors.forename: Koen M
authors.initials: KM
authors.lastname: van Nieuwenhuizen
authors.affiliation: From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands.
authors.forename: Guido J
authors.initials: GJ
authors.lastname: Falcone
authors.affiliation: From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands.
authors.forename: Alison M
authors.initials: AM
authors.lastname: Ayres
authors.affiliation: From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands.
authors.forename: Kristen A
authors.initials: KA
authors.lastname: McNamara
authors.affiliation: From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands.
authors.forename: Kristin
authors.initials: K
authors.lastname: Schwab
authors.affiliation: From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands.
authors.forename: Javier M
authors.initials: JM
authors.lastname: Romero
authors.affiliation: From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands.
authors.forename: Birgitta K
authors.initials: BK
authors.lastname: Velthuis
authors.affiliation: From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands.
authors.forename: Anand
authors.initials: A
authors.lastname: Viswanathan
authors.affiliation: From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Greenberg
authors.affiliation: From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands.
authors.forename: Christopher S
authors.initials: CS
authors.lastname: Ogilvy
authors.affiliation: From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands.
authors.forename: Albert
authors.initials: A
authors.lastname: van der Zwan
authors.affiliation: From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands.
authors.forename: Gabriel J E
authors.initials: GJ
authors.lastname: Rinkel
authors.affiliation: From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands.
authors.forename: Joshua N
authors.initials: JN
authors.lastname: Goldstein
authors.affiliation: From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands.
authors.forename: Catharina J M
authors.initials: CJ
authors.lastname: Klijn
authors.affiliation: From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Rosand
mesh_terms: D000328:Adult; D000368:Aged; D015415:Biomarkers; D016063:Blood Loss, Surgical / Q000503:physiopathology*; D002533:Cerebral Angiography; D002543:Cerebral Hemorrhage / Q000000981:diagnostic imaging* / Q000188:drug therapy / Q000601:surgery; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D019106:Postoperative Hemorrhage / Q000503:physiopathology*; D011237:Predictive Value of Tests; D011379:Prognosis; D012737:Sex Factors; D016037:Single-Blind Method; D014057:Tomography, X-Ray Computed
chemical_list: D015415:Biomarkers; D010975:Platelet Aggregation Inhibitors
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