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AJNR - American Journal of Neuroradiology

Published ahead of print on June 12, 2008
doi: 10.3174/ajnr.A1140

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American Journal of Neuroradiology 29:e80, October 2008
© 2008 American Society of Neuroradiology

Letter

Contrast Extravasation Predicts Hematoma Growth: Where to Now?

R.I. Aviv^a, D. Gladstone^a, J. Goldstein^a, M. Flaherty^a, J. Broderick^a, A. Demchuk^a for the Spot Sign for Predicting and Treating ICH Growth and Spot Sign Selection of ICH to Guide Hemostatic Therapy Investigators

^a Sunnybrook Health Science Centre
Toronto, Ontario, Canada

The findings of Kim et al¹ regarding CT angiography and outcome after intracerebral hemorrhage (ICH) are of importance and complement our previously published work demonstrating an independent association between extravasation, coined the "CT angiogram (CTA) spot sign" and hematoma growth.² Crucially the study by Kim et al¹ also demonstrated an independent association with clinical outcome. A prospective validation study of the CTA spot sign has recently shown a similar result.³ To strengthen current literature, it would be helpful for the authors to provide their working definition of hematoma growth and indicate the diagnostic performance of extravasation for hematoma growth. The number of patients in each group undergoing hematoma growth is also important. The finding of normal CTA with postcontrast CT is significant. How do the authors account for these differences? Did any of these patients demonstrate hematoma expansion? Was there any association with increased international normalized ratio?

In the present study, the mean time to presentation was 10 hours, with a reported incidence of extravasation of 19%–23%. The incidence of the spot sign in our study where patients were scanned within 3 hours was 33%. This suggests a reduction in the risk of extravasation with time. We have demonstrated previously that the specificity of extravasation for hematoma growth is reduced with increasing time to scan,⁴ probably due to nonspecific secondary vascular injury caused by hematoma shearing. These 2 observations argue against an extended time window for intervention, as suggested by the authors.

This study and others provide early evidence of a potentially potent sign that could accurately identify patients at risk of significant hematoma growth. These patients would be ideal candidates for randomized treatment trials of early hemostatic therapy. Two complementary studies (the Spot Sign for Predicting and Treating ICH Growth Study and the Spot Sign Selection of ICH to Guide Hemostatic Therapy Study) are being planned to prospectively evaluate the CTA spot sign for the prediction of hematoma growth. These studies will assess the feasibility of hyperacute CTA investigation and the reliability of spot sign identification in an emergency setting and will provide pilot clinical data by randomly assigning patients with a spot sign to treatment with activated recombinant factor VII or placebo. The exciting findings of Kim et al¹ further emphasize the need for such prospective studies.

References

1. Kim J, Smith A, Hemphill JC 3rd, et al. Contrast extravasation on CT predicts mortality in primary intracerebral hemorrhage. AJNR Am J Neuroradiol 2008;29:520–25[Abstract/Free Full Text]

2. Wada R, Aviv RI, Fox AJ, et al. CT Angiography "spot sign" predicts hematoma expansion in acute intracerebral hemorrhage. Stroke 2007;38:1257–62[Abstract/Free Full Text]

3. Demchuk AM KJ, Tymchuk S, O'Reilly C, et al for the PREDICT/Sunnybrook ICH CTA Study Group. Multicentre prospective study demonstrates feasibility of CT-angiography in intracerebral hemorrhage and validity of "spot sign" for hematoma expansion prediction. International Stroke Conference. New Orleans: February 20–22, 2008.

4. Goldstein JN, Fazen LE, Snider R, et al. Contrast extravasation on CT angiography predicts hematoma expansion in intracerebral hemorrhage. Neurology 2007;68:889–94[Abstract/Free Full Text]

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This Article Full Text (PDF) All Versions of this Article: ajnr.A1140v1 29/9/e80    most recent Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Aviv, R.I. Search for Related Content PubMed PubMed Citation Articles by Aviv, R.I.