Update: Spontaneous intracerebral hemorrhage expansion

Spontaneous intracerebral hemorrhage expansion

Spontaneous intracerebral hemorrhage expansion occurs in about 30% of patients and is related to poor outcome 1).

Patient with prior Warfarin use and intraventricular hemorrhage (IVH) are at risk of hematoma expansion. Aggressive measures to prevent hematoma growth are important in these patients 2).

Hematoma volume HV>16, hematoma heterogeneity HH, 1.5 h-systolic BP SBP>160) can be a practical tool for prediction of ICH growth in the acute stage. Further prospective studies are warranted to validate the ability of this model to predict clinical outcome 3).

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 4).

Large ICHs were significantly more irregular in shape, heterogeneous in density, and had greater growth. Density heterogeneity independently predicted ICH growth using some definitions 5).

The inconsistency in findings may be caused by ambiguous definition of irregular shape.


Very small hematomas are unlikely to expand and have a low spot sign prevalence. Hemostatic therapy trials may be best targeted at hemorrhages >3 mL in volume 6).

Compared with previously reported predictors for hematoma expansion on non-enhanced CT, such as blend signblack hole sign and heterogeneous density, CTA spot sign has better predictive accuracy for hematoma expansion 7) 8) 9).

However, CTA is not available to all medical centers, especially in some remote areas and non-enhanced CT is sometimes the only emergency neuroimaging examination for spontaneous ICH patients. Thus, it is still important to investigate predictors for hematoma expansion on non-enhanced CT.


A non-enhanced computed tomography (CT) based finding, termed the ‘satellite sign‘, was reported to be a novel predictor for poor outcome in spontaneous ICH. However, it is still unclear whether the presence of the satellite sign is related to hematoma expansion.

Initial computed tomography angiography (CTA) was conducted within 6h after ictus. Satellite sign on non-enhanced CT and spot sign on CTA were detected by two independent reviewers. The sensitivity and specificity of both satellite sign and spot sign were calculated. Receiver-operator analysis was conducted to evaluate their predictive accuracy for hematoma expansion.

This study included 153 patients. Satellite sign was detected in 58 (37.91%) patients and spot sign was detected in 38 (24.84%) patients. Among 37 patients with hematoma expansion, 22 (59.46%) had satellite sign and 23 (62.16%) had spot sign. The sensitivity and specificity of satellite sign for prediction of hematoma expansion were 59.46% and 68.97%, respectively. The sensitivity and specificity of spot sign were 62.16% and 87.07%, respectively. The area under the curve (AUC) of satellite sign was 0.642 and the AUC of spot sign was 0.746. (P=0.157)

The results suggest that the satellite sign is an independent predictor for hematoma expansion in spontaneous ICH. Although spot sign has the higher predictive accuracy, satellite sign is still an acceptable predictor for hematoma expansion when CTA is unavailable

Yu et al. compared the predictive values of spot sign and satellite sign for hematoma expansion. Compared with satellite sign, spot sign had higher sensitivity and specificity. In addition, spot sign had a larger AUC than satellite sign, but no significant difference existed. Thus, CTA spot sign seems to be a better predictor for hematoma expansion in spontaneous ICH patients, but satellite sign is still an acceptable predictor for hematoma expansion when CTA is unavailable.

The study has several limitations. First, this was a retrospective study with limited sample size in a single medical center. Second, the association between satellite sign and prognosis was not investigated because of insufficient follow-up data. Furthermore, the onset-to-CTA time was relatively long, which could influence the predictive accuracy of both spot sign and satellite sign.

In conclusion, the study demonstrated that the satellite sign was an independent predictor for hematoma expansion in spontaneous ICH patients. Spot sign has higher accuracy for predicting hematoma expansion, but the satellite sign is still an acceptable predictor when CTA is unavailable. Further multi-center, prospective studies with larger sample sizes are still needed to confirm the utility and validity of the satellite sign in predicting hematoma expansion in spontaneous ICH patients 10).

1)

H.B. Brouwers, Y. Chang, G.J. Falcone, X. Cai, A.M. Ayres, T.W. Battey, A. Vashkevich, K.A. McNamara, V. Valant, K. Schwab, S.C. Orzell, L.M. Bresette, S.K. Feske, N.S. Rost, J.M. Romero, A. Viswanathan, S.H. Chou, S.M. Greenberg, J. Rosand, J.N. Goldstein, Predicting hematoma expansion after primary intracerebral hemorrhage, JAMA Neurol. 1 (2) (2014) 158–164.
2)

Yaghi S, Dibu J, Achi E, Patel A, Samant R, Hinduja A. Hematoma expansion in spontaneous intracerebral hemorrhage: predictors and outcome. Int J Neurosci. 2014 Dec;124(12):890-3. doi: 10.3109/00207454.2014.887716. Epub 2014 Feb 28. PubMed PMID: 24472073.
3)

Takeda R, Ogura T, Ooigawa H, Fushihara G, Yoshikawa S, Okada D, Araki R, Kurita H. A practical prediction model for early hematoma expansion in spontaneous deep ganglionic intracerebral hemorrhage. Clin Neurol Neurosurg. 2013 Jul;115(7):1028-31. doi: 10.1016/j.clineuro.2012.10.016. Epub 2012 Dec 14. PubMed PMID: 23245855.
4) , 7)

Blacquiere D, Demchuk AM, Al-Hazzaa M, Deshpande A, Petrcich W, Aviv RI, Rodriguez-Luna D, Molina CA, Silva Blas Y, Dzialowski I, Czlonkowska A, Boulanger JM, Lum C, Gubitz G, Padma V, Roy J, Kase CS, Bhatia R, Hill MD, Dowlatshahi D; PREDICT/Sunnybrook ICH CTA Study Group. Intracerebral Hematoma Morphologic Appearance on Noncontrast Computed Tomography Predicts Significant Hematoma Expansion. Stroke. 2015 Nov;46(11):3111-6. doi: 10.1161/STROKEAHA.115.010566. Epub 2015 Oct 8. PubMed PMID: 26451019.
5)

Barras CD, Tress BM, Christensen S, MacGregor L, Collins M, Desmond PM, Skolnick BE, Mayer SA, Broderick JP, Diringer MN, Steiner T, Davis SM; Recombinant Activated Factor VII Intracerebral Hemorrhage Trial Investigators. Density and shape as CT predictors of intracerebral hemorrhage growth. Stroke. 2009 Apr;40(4):1325-31. doi: 10.1161/STROKEAHA.108.536888. Epub 2009 Mar 12. PubMed PMID: 19286590.
6)

Dowlatshahi D, Yogendrakumar V, Aviv RI, Rodriguez-Luna D, Molina CA, Silva Y, Dzialowski I, Czlonkowska A, Boulanger JM, Lum C, Gubitz G, Padma V, Roy J, Kase CS, Bhatia R, Hill MD, Demchuk AM; PREDICT/Sunnybrook ICH CTA study group. Small intracerebral hemorrhages have a low spot sign prevalence and are less likely to expand. Int J Stroke. 2016 Feb;11(2):191-7. doi: 10.1177/1747493015616635. PubMed PMID: 26783310.
8)

Zheng J, Yu Z, Xu Z, Li M, Wang X, Lin S, Li H, You C. The Accuracy of the Spot Sign and the Blend Sign for Predicting Hematoma Expansion in Patients with Spontaneous Intracerebral Hemorrhage. Med Sci Monit. 2017 May 12;23:2250-2257. PubMed PMID: 28498827; PubMed Central PMCID: PMC5437917.
9)

Yu Z, Zheng J, Ma L, Guo R, Li M, Wang X, Lin S, Li H, You C. The predictive accuracy of the black hole sign and the spot sign for hematoma expansion in patients with spontaneous intracerebral hemorrhage. Neurol Sci. 2017 Jun 2. doi: 10.1007/s10072-017-3006-6. [Epub ahead of print] PubMed PMID: 28577268.
10)

Yu Z, Zheng J, Ali H, Guo R, Li M, Wang X, Ma L, Li H, You C. Significance of satellite sign and spot sign in predicting hematoma expansion in spontaneous intracerebral hemorrhage. Clin Neurol Neurosurg. 2017 Sep 20;162:67-71. doi: 10.1016/j.clineuro.2017.09.008. [Epub ahead of print] PubMed PMID: 28946021.

Leave a Reply