Alexander E. Merkler, MD 

Brouwers HB, Battey TWK, Musial HH, Ciura VA, Falcone GJ, Ayres AM, et al. Rate of Contrast Extravasation on Computed Tomographic Angiography Predicts Hematoma Expansion and Mortality in Primary Intracerebral Hemorrhage. Stroke. 2015  

Intracerebral hemorrhage (ICH) is associated with a one-month mortality of 40%. Although initial ICH volume is the strongest predictor of mortality, hematoma expansion is a potentially modifiable risk factor that correlates well with both functional outcome and death and occurs in up to 40% of patients with ICH. Research has therefore been focused on methods to 1) identify patients at risk of for hematoma expansion and 2) reduce hematoma expansion.

Although it is still controversial why exactly contrast extravasation occurs, the identification of extravasation of contrast following CTA within an area of ICH, termed the “spot sign,” has been correlated with both hematoma expansion and poor functional outcomes. The sensitivity and positive predictive value of the spot sign are not perfect, though, at about 60% and 50%, respectively.

In their current study, Brouwers et al evaluated whether spot sign growth (or contrast extravasation rate) could further help identify which patients would develop hematoma expansion. 162 patients with primary ICH were included. Each patient received a baseline CTA and then a repeat CTA 90 seconds later. First, the authors confirmed that the spot sign was a reliable predictor of hematoma expansion. Second, a higher extravasation rate was indeed statistically associated with greater hematoma expansion, although the odds ratio was only 1.03 (95% CI 1.01-1.08) in the multivariate analysis. In addition, a higher rate of contrast extravasation was associated with higher in-hospital and 30 day mortality.

Overall, the spot sign is a useful predictor of hematoma growth; the rate of contrast extravasation is an additional imaging characteristic, which may further help identify patients who are likely to undergo hematoma expansion. This study underscores the need to both better predict which patients are likely to develop hematoma expansion and simultaneously discover better strategies to stop hematoma expansion from occurring.