Dynamic spot sign predicts hematoma expansion in acute intraparenchymatous hemorrhage: a perfusion CT study

Abstract

BACKGROUND: Hematoma expansion has been associated with mortality and poor clinical outcome in patients with Intraparenchymatous hemorrhage (IPH). The presence of contrast extravasation (spot sign) detected by CT angiography (CTA) has been considered a good predictive radiologic marker of the hematoma’s expansion and clinical outcome. Despite its good sensibility, a 20% of patients with negative spot sign undergo with posterior hematoma expansion. On the other hand, some studies showed the presence of hypoperfusion in perihematomal area and have tried to relate it to the perihematomal edema. Although there hasn’t been found a correlation between hypoperfusion and perihematomal edema, neither have hypoperfusion and hematoma expansion been studied and correlated with clinical severity and clinical outcome. PURPOSE: The aim of this study is to know whether the perfusion CT increases the sensitivity detecting spot sign as well as to know whether the perihematomal hypoperfusion is associated with subsequent growth of the hematoma and its impact on the prognosis of patients. DESIGN: The study will be an observational prospective cohort study with a duration of 3 years, performed in Josep Trueta Hospital in Girona, Spain. POPULATION: The study population will be all the patients with diagnosis of acute spontaneous intracerebral hemorrhage with a proven initial NCCT scan realized on the emergency department admission and of <12 hours of evolution. A non-probabilistic consecutive sampling will be conducted expecting to gather a minimum sample of 155 patients. The two cohorts (positive and negative spot sign) will be followed in time to analyze hematoma expansion. METHODS: Patients will be studied by a baseline cranial non-contrast CT, perfusion CT and CTA and a non-contrast CT at 24 and 72 hours. The CTA and PCT will assess the presence of spot sign and the difference between the baseline CT and the 24-hours and 72-hours CT will determine the hematoma expansion. Neurological deficit will be evaluated by NIH stroke scale on admission, at 24 hours, 72 hours, 7 days and 90 days after onset. Functional impairment will be assessed by m-Rankin Scale previous to onset and at 90 days