CT Angiography Spot Sign, Hematoma Expansion, and Outcome in Primary Pontine Intracerebral Hemorrhage

Neurocrit Care. 2016 Aug;25(1):79-85. doi: 10.1007/s12028-016-0241-2.


Background and purpose: 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).

Methods: 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.

Results: 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).

Conclusions: 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.

Keywords: Brainstem; CT angiography; Intracerebral hemorrhage; Pontine; Prognosis; Spot sign.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Aged
  • Cohort Studies
  • Computed Tomography Angiography / methods
  • Computed Tomography Angiography / standards*
  • Female
  • Hematoma / diagnostic imaging*
  • Hematoma / pathology*
  • Hospital Mortality*
  • Humans
  • Intracranial Hemorrhages / diagnostic imaging*
  • Intracranial Hemorrhages / pathology*
  • Male
  • Middle Aged
  • Pons / diagnostic imaging*
  • Pons / pathology*
  • Predictive Value of Tests
  • Sensitivity and Specificity