PracticeUpdate: Neurology - Winter 2018

CONFERENCE COVERAGE 14

Australian & New Zealand Association of Neurologists Annual Scientific Meeting 2018 29 MAY–1 JUNE 2018 • DARWIN, AUSTRALIA By the PracticeUpdate Editorial Team CTA Spot Sign Fails to Predict Expansion of Spontaneous Intracerebral Hemorrhage C omputed Tomography Angiography (CTA) spot sign has failed to demon- strate utility in predicting expansion

Recent randomized clinical trials have shown no clinical 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 expan- sion is reasonably accurate, no effective therapeutic intervention is available. Thanh G. Phan, MD, of Monash University in Melbourne, and colleagues first set out to determine whether the presence of the CTA spot sign for expansion of spontane- ous intracerebral hemorrhage is predictive of mortality. PubMed, Medline, conference proceed- ings, and manuscript references up to June 2017 were searched for studies reporting CTA and spot sign or intracerebral hemor- rhage and spot sign. Positive and negative likelihood ratios were calculated using MetaDisc. The positive likelihood ratio needed to be ≥5 and neg- ative likelihood ratio, ≤0.1, to demonstrate clinical utility. Systematic reviews correlating the spot sign to clinical outcome have not been per- formed prior to the present analysis. A total of 36 studies described 6888 patients and

32 clinical outcome measures. Only three outcome measures, however, included suf- ficient comparability across studies. 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 expan- sion were 0.41 (95% CI 0.35–0.47) and 0.8 (95% CI 0.78–0.83) with a plateau 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 demonstrate clinical utility. Dr. Phan and colleagues then set out to determine the predictive value of the spot sign in predicting expansion of spontane- ous intracerebral hemorrhage. PubMed, Medline, conference proceed- ings, and manuscript references up to June 2017 were searched for studies reporting CTA and spot sign or intracerebral hemor- rhage and spot sign. Again, positive and negative likelihood ratios were calculated using MetaDisc, and

of spontaneous intracerebral hemorrhage. Anticoagulant 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. This finding of a retrospective review on mortality prediction and one on intracere- bral hemorrhage growth was reported at ANZAN 2018. Hematoma expansion is a significant pre- dictor of poor outcome in patients with intracerebral hemorrhage. Over the past decade, clinical research in intracerebral hemorrhage has focused on primary injury and hematoma expansion, particularly on early diagnosis and prevention. The spot sign present on CTA is consid- ered a radiological marker for hematoma expansion, with relatively high predictive accuracy. From the standpoint of preven- tion, intensive blood pressure control has been a long-standing physiological target of interest.

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