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Looking for the ‘Spot Sign’: Enlightening the Management of Intracranial Hemorrhage

allow for detecting difference between patients with and without the “spot sign”. Fourth, from sacular and fusiform to lipohialinotic aneurysms, a pathological correlate with the ‘spot sign’ has been described. It is believe that lipohialinosis of the arterial wall in the context of severe hypertension lead to an elongated aneurysmal dilatation, thus predisposing to a traumatic vessel disruption.8-10 The authors proposed a definition for use in clinical and research studies. They suggested that “spot sign” be defined as a spot-like and/or serpiginous foci of enhancement, within the margin of a parenchymal hematoma without connection to outside vessels, greater than 1.5 mm in maximal dimension and has a Hounsfield unit density at least double that of background hematoma density.8 The group has also recently published another study looking at the sensitivity of the “spot sign” to predict hematoma enlargement. They completed a post-contrast CT and a CTA in 61 patients presenting within six hours of primary ICH onset. Hematoma expansion was defined as >6 mL or 30% hematoma enlargement. They found post-contrast leakage (PCL) in 11/61 patients (18%), occurring in five without a spot sign (45%). The inclusion of PCL together with CTA spot sign increased the sensitivity from 0.78 (95% CI; 0.52 to 0.94) to 0.94 (95% CI; 0.72 to 1.00) and the negative predictive value from 0.90 (95% CI; 0.76 to 0.97) to 0.97 (95% CI; 0.85 to 1.00) in the detection of hematoma expansion. Last, but not the least, the presence of the CTA“spot sign” not only correlates with the expansion of the hematoma, but also with clinical outcomes.11 The spot sign in ICH was reported in 33% of patients within three hours and 20% within ten hours, suggesting a reduction in the risk of extravasation with time.11,12