Pseudoaneurysm as a differential for the computed tomography angiography “spot sign” in atypical presentations of intracerebral hemorrhage: illustrative case

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Abstract

BACKGROUND

The computed tomography angiography (CTA) “spot sign” is a well-recognized radiographic marker in primary intracerebral hemorrhage (ICH). Although it has been demonstrated to represent an area of active hemorrhage or contrast extravasation, the exact pathophysiology remains unclear. Vascular mimics of the spot sign have been identified; however, those representing pseudoaneurysm and small vessel aneurysm have rarely been reported.

OBSERVATIONS

A 57-year-old female with a past medical history of hypertension and diabetes mellitus presented with 2 weeks of acute-onset, worsening headache. Computed tomography scanning showed a right interior frontal lobe intraparenchymal hemorrhage. CTA demonstrated a punctate focus of hyperattenuation within the hematoma, consistent with a spot sign, which corresponded to a distal anterior cerebral artery pseudoaneurysm on a cerebral angiogram. The patient subsequently underwent emergent resection of the pseudoaneurysm and hematoma evacuation without complications. Her postoperative course was unremarkable without acute concerns or residual symptoms at the 4-month follow-up.

LESSONS

The authors present a unique case of a distal anterior cerebral artery pseudoaneurysm presenting as a spot sign in a relatively young patient without underlying vascular disease. Given the need for emergent intervention, intracranial pseudoaneurysm is an important diagnosis to consider in the presence of a spot sign in atypical clinical presentations of primary ICH.

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Most cited references 22

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Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign (PREDICT): a prospective observational study.

Andrew M Demchuk, Dar Dowlatshahi, David Rodriguez-Luna … (2012)

In patients with intracerebral haemorrhage (ICH), early haemorrhage expansion affects clinical outcome. Haemostatic treatment reduces haematoma expansion, but fails to improve clinical outcomes in many patients. Proper selection of patients at high risk for haematoma expansion seems crucial to improve outcomes. In this study, we aimed to prospectively validate the CT-angiography (CTA) spot sign for prediction of haematoma expansion. PREDICT (predicting haematoma growth and outcome in intracerebral haemorrhage using contrast bolus CT) was a multicentre prospective observational cohort study. We recruited patients aged 18 years or older, with ICH smaller than 100 mL, and presenting at less than 6 h from symptom onset. Using two independent core laboratories, one neuroradiologist determined CTA spot-sign status, whereas another neurologist masked for clinical outcomes and imaging measured haematoma volumes by computerised planimetry. The primary outcome was haematoma expansion defined as absolute growth greater than 6 mL or a relative growth of more than 33% from initial CT to follow-up CT. We reported data using standard descriptive statistics stratified by the CTA spot sign. Mortality was assessed with Kaplan-Meier survival analysis. We enrolled 268 patients. Median time from symptom onset to baseline CT was 135 min (range 22-470), and time from onset to CTA was 159 min (32-475). 81 (30%) patients were spot-sign positive. The primary analysis included 228 patients, who had a follow-up CT before surgery or death. Median baseline ICH volume was 19·9 mL (1·5-80·9) in spot-sign-positive patients versus 10·0 mL (0·1-102·7) in spot-sign negative patients (p<0·001). Median ICH expansion was 8·6 mL (-9·3 to 121·7) for spot-sign positive patients and 0·4 mL (-11·7 to 98·3) for spot-negative patients (p<0·001). In those with haematoma expansion, the positive predictive value for the spot sign was61% (95% CI 47–73) for the positive predictive value and 78% (71–84) for the negative predictive value, with 51% (39–63) sensitivity and 85% (78–90) specificity[corrected]. Median 3-month modified Rankin Scale (mRS) was 5 in CTA spot-sign-positive patients, and 3 in spot-sign-negative patients (p<0·001). Mortality at 3 months was 43·4% (23 of 53) in CTA spot-sign positive versus 19·6% (31 of 158) in CTA spot-sign-negative patients (HR 2·4, 95% CI 1·4-4·0, p=0·002). These findings confirm previous single-centre studies showing that the CTA spot sign is a predictor of haematoma expansion. The spot sign is recommended as an entry criterion for future trials of haemostatic therapy in patients with acute ICH. Canadian Stroke Consortium and NovoNordisk Canada. Copyright Â© 2012 Elsevier Ltd. All rights reserved.

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CT angiography "spot sign" predicts hematoma expansion in acute intracerebral hemorrhage.

Mary A. Fox, R Wada, D Gladstone … (2007)

Morbidity and mortality in spontaneous intracerebral hemorrhage (ICH) are correlated with hematoma progression. We hypothesized that the presence of tiny, enhancing foci ("spot sign") within acute hematomas is associated with hematoma expansion. We prospectively studied 39 consecutive patients with spontaneous ICH by computed tomography angiography within 3 hours of symptom onset. Scans were reviewed by 3 readers. Patients were dichotomized according to the presence or absence of the spot sign. Clinical and radiological outcomes were compared between groups. The predictive value of this sign was assessed in a multivariate analysis. Thirteen patients (33%) demonstrated 31 enhancing foci. Baseline clinical variables were similar in both groups. Hematoma expansion occurred in 11 patients (28%) on follow-up. Seventy-seven percent of patients with and 4% without hematoma expansion demonstrated the spot sign (P<0.0001). Sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio for expansion were 91%, 89%, 77%, 96%, and 8.5, respectively. Interobserver agreement was high (kappa=0.92 to 0.94). In patients with the spot sign, mean volume change was greater (P=0.008), extravasation more common (P=0.0005), and median hospital stay longer (P=0.04), and fewer patients achieved a good outcome (modified Rankin Scale score <2), although the latter was not significant (P=0.16). No differences in hydrocephalus (P=1.00), surgical intervention (P=1.00), or death (P=0.60) were noted between groups. In multiple regression, the spot sign independently predicted hematoma expansion (P=0.0003). The computed tomography angiography spot sign is associated with the presence and extent of hematoma progression. Fewer patients achieve a good clinical outcome and hospital stay was longer. Further studies are warranted to validate the ability of this sign to predict clinical outcomes.

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Intracerebral hemorrhage outcome: A comprehensive update

Joao Rr Pinho, Ana Costa, José Manuel Araújo … (2019)

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Author and article information

Journal

Journal ID (nlm-ta): J Neurosurg Case Lessons

Journal ID (iso-abbrev): J Neurosurg Case Lessons

Journal ID (publisher-id): J Neurosurg Case Lessons

Title: Journal of Neurosurgery: Case Lessons

Publisher: American Association of Neurological Surgeons

ISSN (Electronic): 2694-1902

Publication date Collection: 7 November 2022

Publication date (Electronic): 7 November 2022

Volume: 4

Issue: 19

Electronic Location Identifier: CASE22308

Affiliations

[1]Division of Neurosurgery, Saint Louis University School of Medicine, St. Louis, Missouri

Author notes

Correspondence Jeroen Coppens: Saint Louis University School of Medicine, St. Louis, MO. jeroen.coppens@ 123456health.slu.edu .

INCLUDE WHEN CITING Published November 7, 2022; DOI: 10.3171/CASE22308.

Disclosures Dr. Coppens reported personal fees from NICO Corporation outside the submitted work. No other disclosures were reported.

Article

Publisher ID: CASE22308

DOI: 10.3171/CASE22308

PMC ID: 9644414

PubMed ID: 36345204

SO-VID: 1cba6186-c367-4968-bcec-3b29ae29fcee

License:

CC BY-NC-ND 4.0 ( http://creativecommons.org/licenses/by-nc-nd/4.0/).

History

Date received : 25 July 2022

Date accepted : 15 September 2022

Page count

Figures: 4, Tables: 0, References: 22, Pages: 4

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