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Intracerebral Hematoma Morphologic Appearance on Noncontrast Computed Tomography Predicts Significant Hematoma
Dylan Blacquiere1, Andrew M Demchuk2, Mohammed Al-Hazzaa2
1From the Calgary Stroke Program, Departments of Clinical Neurosciences (A.M.D., M.D.H.) and Radiology (A.M.D., M.D.H.), Hotchkiss Brain Institute, University of Calgary, Calgary, Canada; Department of Neurology, National Neuroscience Institution, King Fahad Medical City, Riyadh, Saudi Arabia (M.A.-H.); Department of Neurology at Kasturba Medical College, Manipal, Karnataka, India (A.D.); Methods Centre, Department of Clinical Epidemiology (W.P.), Neuroradiology Section, Department of Diagnostic Imaging (C.L.), and Department of Medicine (Neurology) (D.D.), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada; Division of Neuroradiology, Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada (R.I.A.); Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.); Department of Neurology, Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona (IDIBGi) Foundation, Girona, Spain (Y.S.B.); Department of Neurology, University of Dresden, Dresden, Germany (I.D.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.C.); Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland (A.C.); Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada (J.-M.B.); Department of Neurology, Dalhousie University, Halifax, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi, India (V.P., R.B.); Department of Neuromedicine, AMRI Neurosciences Centre, Mukundapur, India (J.R.); Department of Neurology, Boston Medical Center, MA (C.S.K.); and Division of Neurology, Department of Medicine, Dalhousie University, Saint John Regional Hospital, Saint John, New Brunswick, Canada (D.B.). Dylan.Blacquiere@HorizonNB.ca.
Background And Purpose:
Hematoma expansion in intracerebral hemorrhage is associated with higher morbidity and mortality. The computed tomography (CT) angiographic spot sign is highly predictive of expansion, but other morphological features of intracerebral hemorrhage such as fluid levels, density heterogeneity, and margin irregularity may also predict expansion, particularly in centres where CT angiography is not readily available.
Methods:
Baseline noncontrast CT scans from patients enrolled in the Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT (PREDICT) study were assessed for the presence of fluid levels and degree of density heterogeneity and margin irregularity using previously validated scales. Presence and grade of these metrics were correlated with the presence of hematoma expansion as defined by the PREDICT study on 24-hour follow-up scan.
Results:
Three hundred eleven patients were included in the analysis. The presence of fluid levels and increasing heterogeneity and irregularity were associated with 24-hour hematoma expansion (P=0.021, 0.003 and 0.049, respectively) as well as increases in absolute hematoma size. Fluid levels had the highest positive predictive value (50%; 28%-71%), whereas margin irregularity had the highest negative predictive value (78%; 71%-85). Noncontrast metrics had comparable predictive values as spot sign for expansion when controlled for vitamin K, antiplatelet use, and baseline National Institutes of Health Stroke Scale, although in a combined area under the receiver-operating characteristic curve model, spot sign remained the most predictive.
Conclusions:
Fluid levels, density heterogeneity, and margin irregularity on noncontrast CT are associated with hematoma expansion at 24 hours. These markers may assist in prediction of outcomes in scenarios where CT angiography is not readily available and may be of future help in refining the predictive value of the CT angiography spot sign.
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