American Heart Association


Spotting the SPOT sign by using a delayed CT angiogram sequence

It is common knowledge amongst the stroke community that a spot sign seen on a CT angiogram predicts hematoma expansion in patients with Intracerebral hemorrhage (ICH).  Size of the hematoma is an independent predictor of poor outcome and all attempts are made to prevent the increase in size by use of hemostatic medications and blood pressure control. The authors of this study hypothesize that addition of a 90 second delayed CT would help capture additional ICH patients with the spot sign and increase the sensitivity for predicting hematoma expansion and poor outcome. Patients with spontaneous ICH were enrolled prospectively between February 2012 and August 2013 and underwent a non-contrast head CT, immediately followed by CTA of the head with a 90 second delayed acquisition through the hematoma volume.

All CTA studies were independently reviewed by two board-certified radiologists and the spot sign was identified as a focus of contrast pooling within the ICH with an attenuation ≥120 HU that was discontinuous from normal or abnormal vasculature adjacent to the ICH and was of any size and morphology. Hematoma expansion was considered significant if the volume increased by 6ml or by 33% from baseline. A multivariate logistic regression model was utilized to analyze data and sensitivity, specificity and positive/negative predictive values were calculated.

A total of 121 patients were enrolled in the study however only 74 had follow up CT scans and were included in the primary analysis. A total of 15 patients had a positive spot sign detected on any CTA and the overall rate of hematoma expansion was 15%. Hematoma expansion was predominantly seen in the spot sign positive group (47% vs. 7%). Accuracy measures for the spot sign on delayed CTA were: sensitivity 55%, specificity 87%, PPV 43%, NPV 92%, accuracy 82%. When the CT scans for all 121 patients were analyzed the spot sign was seen on 36 scans, with 15 detected exclusively on the delayed 90 second imaging. The presence of a spot sign and high blood glucose levels were independent predictors of mortality in the multivariate logistic regression model. Greater than 95% of these patients with a positive spot sign were dead at follow up.
This study re-enforces that spot sign is a predictor of hematoma expansion and poor outcome. The 90 second sequence is cost effective and time efficient however the numbers in the study are really small. The question arises – are we going to try everything to detect a spot sign? The authors conclude that the delayed 90 second sequence may help select patients eligible hemostatic intervention but we need to ask ourselves if it really changes clinical practice. Although the spot sign is predictive of expansion, it is only seen in a small percent of patients with ICH and a delayed CT has a sensitivity of 55% to detect a spot sign.  If a safe hemostatic medication is available and approved, I wonder if we would be so selective in its use.  Let’s reserve our judgement till the  SPOTLIGHT (spot sign selection of intracerebral hemorrhage to guide hemostatic therapy trial)  is on ICH treatment with hemostatic therapy. 
By |October 28th, 2014|hemorrhage|0 Comments

Characteristics of Intracerebral Hemorrhage in Rivaroxaban vs. Warfarin

Abdel Salam Kaleel, MD, MSc

Hagii J, Tomita H, Metoki N, Saito S, Shiroto H, Hitomi H, et al. Characteristics of Intracerebral Hemorrhage During Rivaroxaban Treatment: Comparison With Those During Warfarin. Stroke. 2014

This study compared the clinical characteristics, neuroradiologic findings, and functional outcomes of patients taking rivaroxaban and patients taking warfarin for nonvalvular atrial fibrillation who subsequently developed intracerebral hemorrhages. In particular, it sought to determine which group had more favorable characteristics after ICH. This study was conducted between April 2011 and October 2013 in the Hirosaki Stroke and Rehabilitation Center and included 585 ICH patients, 5 of whom had ICH while taking rivaroxaban, 56 of whom had ICH while taking warfarin, and 524 of whom had ICH on no anticoagulant therapy. ICH was diagnosed by immediate computed tomography (CT) with a follow up scan at day 2
after admission. The hematoma volume, expansion of hematoma, and extent of cerebral microbleeds were determined in surviving patients; Vitamin K was given for reversal of anticoagulation in patients on warfarin, but no reversal was given for patients previously on rivaroxaban. Scales and scores, namely CHADS2, HAS-BLED, and modified Rankin Scales, were determined on each patient. The differences were then computed by Mann-Whitney U test or Fisher’s exact test. 

Interestingly, patients on rivaroxaban had a smaller hematoma volume while none of them had expansion of hematoma or underwent surgical treatment. Those patients who had been taking warfarin on admission experienced expansion of hematoma in 21% and required surgical treatment in 11%. These findings occurred in the setting of rivaroxaban-treated patients having more cerebral microbleeds than the warfarin-treated group. When comparing the patients with mRS of 0 and 1 before admission, none of the patients in the rivaroxaban group had mRS >4 at discharge, but half of the patients taking warfarin did. Additionally, ten of the warfarin-treated patients died whereas none of the rivaroxaban-treated patients did. While the study did have several limitations, including single-center retrospective analysis and small number of study patients, it did provide valuable comparisons and some insight in characteristics of patients who suffered from ICH while taking warfarin or rivaroxaban.
By |August 20th, 2014|hemorrhage|0 Comments