Ultra-early computed tomography markers of haematoma expansion: Potential trial targets?

The predictive value of CT markers of intracerebral haemorrhage (ICH) expansion is time-dependent, but data in the ultra-early period (<2 h from onset) are limited. We aimed to describe the frequency of these CT markers, their association with haematoma volume, haematoma expansion (HE) and functional outcome at 90-days. We also investigated the effect of tranexamic acid on HE in the presence of these markers.

We performed a pooled analysis of individual patient data from the STOP-AUST and STOP-MSU placebo-controlled randomised trials of tranexamic acid, including ICH patients scanned within 2 h of symptom onset. Logistic regression was used to assess the association between CT markers and HE or 90-days functional outcomes (poor outcome defined as mRS3-6).

Among 246 patients, the swirl sign (74.3%) was the most frequent CT marker and the blend sign least frequent (7.3%). All markers were associated with increased baseline haematoma volume, and excluding the black hole sign, all were more common in patients with 24-h HE. The blend and spot signs were associated with 24-h HE and heterogenous density, swirl sign, hypodensity and island sign were associated with poor 90-day function outcomes in univariate logistic regression. However, the area under the receiver-operating-characteristic curve was similar for all markers and indicated low discriminative ability (Chi-squared test p = 0.81). A potential benefit of tranexamic acid in HE reduction was observed in patients with the spot sign (interaction p = 0.01).

The discriminative utility of CT markers of HE in the early timeframe appears insufficient. There may be an effect of tranexamic acid in spot sign positive patients <2 h from onset.