PracticeUpdate Conference Series - ANZAN 2018

CTASpot SignFails to Predict Expansion of Spontaneous Intracerebral Hemorrhage

Computed Tomography Angiography (CTA) spot sign has failed to demonstrate utility in predicting expansion of spontaneous intracerebral hemorrhage. A nticoagulant use among patients who present with transient ischemic attack (TIA) or stroke remains inadequate. Improved screening for atrial fibrillation in patients presenting with TIA or stroke is needed. Systematic reviews correlating the spot sign to clinical outcome have not been performed prior to the present analysis. A total of 36 studies described 6888 patients and 32 clinical outcome measures. Only three outcome measures, however, included sufficient comparability across studies.

This finding of a retrospective review on mortality prediction and one on intracerebral hemorrhage growth was reported at ANZAN 2018. Hematoma expansion is a significant predictor of poor outcome in patients with intracerebral hem- orrhage. Over the past decade, clinical research in intracerebral hemorrhage has focused on primary injury and hematoma expansion, particularly on early diagnosis and prevention.

Positive and negative likelihood ratios for in-hospital mortality by spot sign were 2.47 (95% CI 1.59–3.82) and 0.62 (95% CI 0.46–0.82), with a plateau of 2.7 and 0.6, respectively, across 10 studies. Positive and negative likelihood ratios for 3-month mortality due to hematoma expansion were 0.41 (95% CI 0.35–0.47) and 0.8 (95% CI 0.78–0.83) with a pla- teau of 2.0 and 0.8, respectively, across eight studies. Positive and negative likelihood ratios did not meet respective thresholds of 5 and 0.1 required to demon- strate clinical utility. Dr. Phan and colleagues then set out to determine the predictive value of the spot sign in predicting expansion of spontaneous intracerebral hemorrhage. PubMed, Medline, conference proceedings, and manuscript references up to June 2017 were searched for studies reporting CTA and spot sign or intracerebral hemorrhage and spot sign. Again, positive and negative likelihood ratios were calculated using MetaDisc, and the positive likelihood ratio needed to be ≥5 and negative likelihood ratio, ≤0.1, to demonstrate clinical utility. A total of 36 studies described 6888 patients. The analysis included 23 studies not incorporated into previous meta-analyses. Hematoma grew at a frequency of 21%. Positive and negative likelihood ratios for the CTA spot sign indi- cating hematoma growth were 4.25 (95%CI 3.52–5.13) and 0.48 (95% CI 0.41–0.56), respectively. Sensitivity analyses showed a plateau in positive and negative likelihood ratios of 4.3 and 0.48, respec- tively. Heterogeneity chi square was 214.36–250.24 (P < .001) and inconsistency I2, 83.7–86%. Dr. Phan concluded that the positive likelihood ratio for the CTA spot sign did not reach the threshold of 5 to demonstrate clinical utility. Heterogeneity regarding this estimate added to uncertainty. The high negative likelihood ratio suggested that absence of the CTA spot sign does not guarantee a lack of growth of intracerebral hemorrhage. CTA spot sign predicted neither mortality from nor expansion of spontaneous intracerebral hemorrhage.

" The high negative likelihood ratio suggested that absence of the CTA spot sign does not guarantee a lack of growth of intracerebral hemorrhage. "

The spot sign present on CTA is considered a radiological marker for hematoma expansion, with rel- atively high predictive accuracy. From the standpoint of prevention, intensive blood pressure control has been a long-standing physiological target of interest. Recent randomized clinical trials have shown no clini- cal benefit of aggressive blood pressure reduction in the acute phase of intracerebral hemorrhage, how- ever. These results imply that while early diagnosis of impending hematoma expansion is reasonably accu- rate, no effective therapeutic intervention is available. Thanh G. Phan, MD, of Monash University in Melbourne, and colleagues first set out to deter- mine whether the presence of the CTA spot sign for expansion of spontaneous intracerebral hemorrhage is predictive of mortality. PubMed, Medline, conference proceedings, and manuscript references up to June 2017 were searched for studies reporting CTA and spot sign or intracerebral hemorrhage and spot sign. Positive and negative likelihood ratios were calcu- lated using MetaDisc. The positive likelihood ratio needed to be ≥5 and negative likelihood ratio, ≤0.1, to demonstrate clinical utility.

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