title: CT Angiography Spot Sign, Hematoma Expansion, and Outcome in Primary Pontine Intracerebral Hemorrhage.
abstract: The computed tomography angiography (CTA) spot sign is a validated predictor of hematoma expansion and poor outcome in supratentorial intracerebral hemorrhage (ICH), but patients with brainstem ICH have typically been excluded from the analyses. We investigated the frequency of spot sign and its relationship with hematoma expansion and outcome in patients with primary pontine hemorrhage (PPH).
  
  
  
  We performed a retrospective analysis of PPH cases obtained from a prospectively collected cohort of consecutive ICH patients who underwent CTA. CTA first-pass readings for spot sign presence were analyzed by two trained readers. Baseline and follow-up hematoma volumes on non-contrast CT scans were assessed by semi-automated computer-assisted volumetric analysis. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive and negative likelihood ratio, and accuracy of spot sign for prediction of in-hospital mortality were calculated.
  
  
  
  49 subjects met the inclusion criteria of whom 11 (22.4 %) showed a spot sign. In-hospital mortality was higher in spot sign-positive versus spot sign-negative subjects (90.9 vs 47.4 %, p = 0.020). Spot sign showed excellent specificity (95 %) and PPV (91 %) in predicting in-hospital mortality. Absolute hematoma growth, defined as parenchymal and intraventricular hematoma expansion of any amount, was significantly higher in spot sign-positive versus spot sign-negative subjects (13.72 ± 20.93 vs 3.76 ± 8.55 mL, p = 0.045).
  
  
  
  As with supratentorial ICH, the CTA spot sign is a common finding and is associated with higher risk of hematoma expansion and mortality in PPH. This marker may assist clinicians in prognostic stratification.
authors.affiliation: Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy.|Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.|Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Andrea
authors.initials: A
authors.lastname: Morotti
authors.affiliation: Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.|Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Jessel
authors.affiliation: Department of Neurosurgery, Brain Center Rudolf Magnus University Medical Center, Utrecht, The Netherlands.
authors.forename: H Bart
authors.initials: HB
authors.lastname: Brouwers
authors.affiliation: Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.|Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Guido J
authors.initials: GJ
authors.lastname: Falcone
authors.affiliation: Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Kristin
authors.initials: K
authors.lastname: Schwab
authors.affiliation: Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Alison M
authors.initials: AM
authors.lastname: Ayres
authors.affiliation: Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Anastasia
authors.initials: A
authors.lastname: Vashkevich
authors.affiliation: Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.|Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Christopher D
authors.initials: CD
authors.lastname: Anderson
authors.affiliation: Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Anand
authors.initials: A
authors.lastname: Viswanathan
authors.affiliation: Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Greenberg
authors.affiliation: Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: M Edip
authors.initials: ME
authors.lastname: Gurol
authors.affiliation: Neuroradiology Service, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Javier M
authors.initials: JM
authors.lastname: Romero
authors.affiliation: Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.|Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Rosand
authors.affiliation: Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA. jgoldstein@partners.org.|Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA. jgoldstein@partners.org.|Department of Emergency Medicine, Massachusetts General Hospital, Zero Emerson Place, Suite 3B, Boston, MA, 02114, USA. jgoldstein@partners.org.
authors.forename: Joshua N
authors.initials: JN
authors.lastname: Goldstein
mesh_terms: D000368:Aged; D015331:Cohort Studies; D000072226:Computed Tomography Angiography / Q000379:methods / Q000592:standards*; D005260:Female; D006406:Hematoma / Q000000981:diagnostic imaging* / Q000473:pathology*; D017052:Hospital Mortality; D006801:Humans; D020300:Intracranial Hemorrhages / Q000000981:diagnostic imaging* / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D011149:Pons / Q000000981:diagnostic imaging* / Q000473:pathology*; D011237:Predictive Value of Tests; D012680:Sensitivity and Specificity
keywords: Brainstem; CT angiography; Intracerebral hemorrhage; Pontine; Prognosis; Spot sign