title: Small intracerebral hemorrhages have a low spot sign prevalence and are less likely to expand.
abstract: BACKGROUND
  Hematoma expansion is a major predictor of morbidity and mortality after intracerebral hemorrhage (ICH). Both baseline hematoma volume and the CT-angiogram (CTA) spot sign predict hematoma expansion. Because the CTA spot sign may represent foci of active hemorrhage, we hypothesized that patients with smaller baseline hematoma volumes are less likely to be spot sign positive, and therefore less likely to expand.
  
  
  OBJECTIVE
  We sought to validate our prior finding that small hematomas are unlikely to expand, and to determine the relationship between baseline hematoma volume, spot sign status, and risk of hematoma expansion.
  
  
  METHODS
  Data were from the prospective PREDICT ICH study. Patients presenting within 6 h of symptom onset with completed baseline CT, CTA, and follow-up CT were included. Baseline hematoma volume was categorized a priori (<3 mL, 3-10 mL, 10-20 mL, >20 mL). The primary outcome was significant hematoma expansion (≥6 mL, ≥12.5 mL or ≥33%) and secondary outcomes were early neurological worsening, good clinical outcome (modified Rankin Scale 0-3), and mortality at 90 days.
  
  
  RESULTS
  Among 315 patients meeting the inclusion criteria, baseline hematoma volume category predicted absolute hematoma expansion (p < 0.001), spot sign prevalence (p < 0.001), early neurologic worsening (p = 0.002), clinical outcome (p < 0.001), and mortality (p < 0.001). Very small hematomas (<3 mL) were unlikely to be spot positive (7.7%), unlikely to expand (2.6%), and were associated with a 73% chance of good clinical outcome. Spot sign appeared to be most predictive of expansion in the 3-10 mL baseline hematoma volume category.
  
  
  CONCLUSIONS
  Very small hematomas are unlikely to expand and have a low spot sign prevalence. Hemostatic therapy trials may be best targeted at hemorrhages >3 mL in volume.
authors.affiliation: Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Canada ddowlat@toh.on.ca.
authors.forename: Dar
authors.initials: D
authors.lastname: Dowlatshahi
authors.affiliation: Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Canada.
authors.forename: Vignan
authors.initials: V
authors.lastname: Yogendrakumar
authors.affiliation: Division of Neuroradiology and Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.
authors.forename: Richard I
authors.initials: RI
authors.lastname: Aviv
authors.affiliation: Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.
authors.forename: David
authors.initials: D
authors.lastname: Rodriguez-Luna
authors.affiliation: Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Molina
authors.affiliation: Department of Neurology, Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona (IDIBGi) Foundation, Girona, Spain.
authors.forename: Yolanda
authors.initials: Y
authors.lastname: Silva
authors.affiliation: Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany.
authors.forename: Imanuel
authors.initials: I
authors.lastname: Dzialowski
authors.affiliation: 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland.
authors.forename: Anna
authors.initials: A
authors.lastname: Czlonkowska
authors.affiliation: Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada.
authors.forename: Jean-Martin
authors.initials: JM
authors.lastname: Boulanger
authors.affiliation: Department of Diagnostic Imaging, Neuroradiology Section, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada.
authors.forename: Cheemun
authors.initials: C
authors.lastname: Lum
authors.affiliation: Department of Neurology, Dalhousie University, Halifax, Canada.
authors.forename: Gord
authors.initials: G
authors.lastname: Gubitz
authors.affiliation: Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Vasantha
authors.initials: V
authors.lastname: Padma
authors.affiliation: AMRI Neurosciences Center, Mukundapurz, Kolkata, India.
authors.forename: Jayanta
authors.initials: J
authors.lastname: Roy
authors.affiliation: Department of Neurology, Boston Medical Center, Boston, USA.
authors.forename: Carlos S
authors.initials: CS
authors.lastname: Kase
authors.affiliation: Department of Neurology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Rohit
authors.initials: R
authors.lastname: Bhatia
authors.affiliation: Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada Calgary Stroke Program, Department of Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Hill
authors.affiliation: Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada Calgary Stroke Program, Department of Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada.
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Demchuk
mesh_terms: D000368:Aged; D002533:Cerebral Angiography; D002543:Cerebral Hemorrhage / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging; D018450:Disease Progression; D005260:Female; D006406:Hematoma / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging; D006801:Humans; D008297:Male; D011237:Predictive Value of Tests; D014057:Tomography, X-Ray Computed
keywords: Intracerebral hemorrhage; hematoma expansion; hemorrhagic stroke; prognosis; spot sign