The spot sign in intracerebral hemorrhage: the importance of looking for contrast extravasation

Cerebrovasc Dis. 2010 Feb;29(3):217-20. doi: 10.1159/000267842. Epub 2009 Dec 18.


Background: The 'spot sign' is a bright spot on computerized tomography angiography (CTA) source images predictive of hematoma growth. Contrast extravasation (CE) is seen on routine head CT following CTA as pooling of contrast within the hematoma. Our aim was to re-evaluate the predictive value of both the spot sign and CE and measure the reliability of scoring them.

Methods: Consecutive cases of spontaneous intracerebral hemorrhage (ICH) presenting within 4 h. The presence of a 'spot' and CE, ICH and intraventricular hemorrhage volume at baseline and on follow-up scans were assessed. Clinical outcome was captured using the modified Rankin Scale on hospital discharge.

Results: We identified 28 patients with a mean age of 56.8 years, median ICH volume of 19 ml, and median NIH Stroke Scale score on admission of 17.5. 11/27 (40.7%) had a positive spot and 13/22 (59.1%) had CE. Interrater reliability was 0.812 (95% CI 0.57-0.91, p < 0.001) for the spot sign and 0.952 (95% CI 0.89-0.98, p < 0.001) for CE. ICH volume increased in 16/28 (57.1%) patients. Both the spot sign and CE were associated with ICH growth (p < 0.001) and poor outcome (p < 0.001).

Conclusions: In ICH patients, the presence of the spot sign or CE is highly correlated with early ICH growth. In our experience, CE is a more sensitive predictor of ICH growth with a better negative predictive value than the spot sign; CE is more consistently identified even by experienced clinicians. Postcontrast CT should be done routinely after CTA in patients presenting with ICH within 4 h. Patients who are CE-positive may be candidates for hemostatic therapies or early surgical intervention.

MeSH terms

  • Cerebral Angiography / methods*
  • Cerebral Hemorrhage / complications
  • Cerebral Hemorrhage / diagnostic imaging*
  • Contrast Media*
  • Extravasation of Diagnostic and Therapeutic Materials / diagnostic imaging
  • Extravasation of Diagnostic and Therapeutic Materials / etiology*
  • Hematoma / diagnostic imaging*
  • Hematoma / etiology
  • Humans
  • Logistic Models
  • Middle Aged
  • Observer Variation
  • Odds Ratio
  • Patient Discharge
  • Predictive Value of Tests
  • Prognosis
  • Prospective Studies
  • Reproducibility of Results
  • Risk Assessment
  • Risk Factors
  • Severity of Illness Index
  • Time Factors
  • Tomography, X-Ray Computed*


  • Contrast Media