J Stroke.  2021 Jan;23(1):82-90. 10.5853/jos.2020.03531.

Dual-Energy CT Angiography Improves Accuracy of Spot Sign for Predicting Hematoma Expansion in Intracerebral Hemorrhage

Affiliations
  • 1Department of Neurology and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
  • 2Department of Radiology and Nuclear Medicine, MHeNS School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, Netherlands

Abstract

Background and Purpose
Spot sign (SS) on computed tomography angiography (CTA) is associated with hematoma expansion (HE) and poor outcome after intracerebral hemorrhage (ICH). However, its predictive performance varies across studies, possibly because differentiating hyperdense hemorrhage from contrast media is difficult. We investigated whether dual-energy-CTA (DE-CTA), which can separate hemorrhage from iodinated contrast, improves the diagnostic accuracy of SS for predicting HE.
Methods
Primary ICH patients undergoing DE-CTA (both arterial as well as delayed venous phase) and follow-up computed tomography were prospectively included between 2014 and 2019. SS was assessed on both arterial and delayed phase images of the different DE-CTA datasets, i.e., conventional-like mixed images, iodine images, and fusion images. Diagnostic accuracy of SS for prediction of HE was determined on all datasets. The association between SS and HE, and between SS and poor outcome (modified Rankin Scale at 3 months ≥3) was assessed with multivariable logistic regression, using the dataset with highest diagnostic accuracy.
Results
Of 139 included patients, 47 showed HE (33.8%). Sensitivity of SS for HE was 32% (accuracy 0.72) on conventional-like mixed arterial images which increased to 76% (accuracy 0.80) on delayed fusion images. Presence of SS on delayed fusion images was independently associated with HE (odds ratio [OR], 17.5; 95% confidence interval [CI], 6.14 to 49.82) and poor outcome (OR, 3.84; 95% CI, 1.16 to 12.73).
Conclusions
Presence of SS on DE-CTA, in particular on delayed phase fusion images, demonstrates higher diagnostic performance in predicting HE compared to conventional-like mixed imaging, and it is associated with poor outcome.

Keyword

Computed tomography angiography; Cerebral hemorrhage; Intracranial hemorrhages; Spot sign; Prognosis

Figure

  • Figure 1. An 81-year old man with primary intracerebral hemorrhage (ICH) in the left thalamus. (A) Non-contrast baseline computed tomography (CT) (left) and non-contrast follow-up CT after 24 hours (right). (B) Mixed arterial image (left) and mixed delayed image (right). (C) Arterial iodine image (left) and delayed iodine image (right) with spot sign (SS) (arrow). (D) Arterial fusion image (left) and delayed fusion image (right) with SS (arrow). Arterial images did not show a SS. A SS can clearly be seen on delayed iodine (C, right panel) and fusion images (D, right panel), but could not be distinguished from hyperintense hemorrhage signal on conventional-like mixed delayed image (B, right panel). In this case, significant hematoma expansion took place (A).

  • Figure 2. Flow-chart of selection study cohort. ICH, intracerebral hemorrhage; DE-CT, dual-energy computed tomography; CT, computed tomography.


Reference

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