Predicting Intracerebral Hemorrhage Growth With the Spot Sign: The Effect of Onset-to-Scan Time

Stroke. 2016 Mar;47(3):695-700. doi: 10.1161/STROKEAHA.115.012012. Epub 2016 Feb 4.


Background and purpose: Hematoma expansion after acute intracerebral hemorrhage is common and is associated with early deterioration and poor clinical outcome. The computed tomographic angiography (CTA) spot sign is a promising predictor of expansion; however, frequency and predictive values are variable across studies, possibly because of differences in onset-to-CTA time. We performed a patient-level meta-analysis to define the relationship between onset-to-CTA time and frequency and predictive ability of the spot sign.

Methods: We completed a systematic review for studies of CTA spot sign and hematoma expansion. We subsequently pooled patient-level data on the frequency and predictive values for significant hematoma expansion according to 5 predefined categorized onset-to-CTA times. We calculated spot-sign frequency both as raw and frequency-adjusted rates.

Results: Among 2051 studies identified, 12 met our inclusion criteria. Baseline hematoma volume, spot-sign status, and time-to-CTA were available for 1176 patients, and 1039 patients had follow-up computed tomographies for hematoma expansion analysis. The overall spot sign frequency was 26%, decreasing from 39% within 2 hours of onset to 13% beyond 8 hours (P<0.001). There was a significant decrease in hematoma expansion in spot-positive patients as onset-to-CTA time increased (P=0.004), with positive predictive values decreasing from 53% to 33%.

Conclusions: The frequency of the CTA spot sign is inversely related to intracerebral hemorrhage onset-to-CTA time. Furthermore, the positive predictive value of the spot sign for significant hematoma expansion decreases as time-to-CTA increases. Our results offer more precise risk stratification for patients with acute intracerebral hemorrhage and will help refine clinical prediction rules for intracerebral hemorrhage expansion.

Keywords: CT angiography; cerebral hemorrhage; hematoma expansion; intracerebral hemorrhage; spot sign.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Cerebral Angiography / methods
  • Cerebral Angiography / trends*
  • Cerebral Hemorrhage / diagnostic imaging*
  • Cerebral Hemorrhage / epidemiology
  • Disease Progression*
  • Hematoma / diagnostic imaging*
  • Hematoma / epidemiology
  • Humans
  • Predictive Value of Tests
  • Time Factors
  • Tomography, X-Ray Computed / methods
  • Tomography, X-Ray Computed / trends*