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CTA Spot Sign

Summary

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  • One or more foci of contrast within an acute intracerebral haematoma on CT angiography, representing active contrast extravasation
  • A strong predictor of haematoma expansion and is associated with worse clinical outcome
  • Distinct from the CTA "dot sign", which is intraluminal thrombus in a distal MCA branch in acute ischaemic stroke1

Imaging Appearance

  • Basis of the sign:
    • Active extravasation of contrast from ruptured small vessels within an acute intracerebral haematoma, reflecting ongoing bleeding
  • Identified on CT angiography source images, with commonly applied criteria for a spot:
    • One or more foci of contrast within the haematoma
    • Discontinuous from adjacent normal or abnormal vasculature
    • Attenuation of at least 120 HU
    • Any size or morphology
  • Delayed / post-contrast acquisitions:
    • Increase sensitivity by demonstrating contrast leakage or pooling that increases on delayed-phase imaging

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  • A 60-year-old patient presented with left sided weakness and paraesthesia.
  • Imaging showed a focus of enhancement within a right thalamic haematoma.
  • A follow-up CT showed enlargement of the haematoma.

Clinical Relevance

  • Most often seen in spontaneous (primary) intracerebral haemorrhage, including hypertensive and cerebral amyloid angiopathy-related bleeds
  • More frequent with larger haematomas, earlier imaging after symptom onset, anticoagulant use and coagulopathy
  • A prognostic marker rather than a target for direct treatment:
    • The number, size and attenuation of spots (the "spot sign score") stratify the risk of expansion and predict haematoma growth on follow-up non-contrast CT
    • Identifies patients who warrant close monitoring for haematoma expansion
  • Management is directed at the underlying haemorrhage:
    • Blood pressure control
    • Reversal of anticoagulation and correction of coagulopathy
    • Neurosurgical evaluation for evacuation in selected patients
  • Note: intravenous thrombolysis is contraindicated in intracerebral haemorrhage

Differential diagnosis

Imaging differential Differentiating feature
Calcification within the haematoma Present and dense on the non-contrast scan; does not represent contrast
Aneurysm or vascular malformation Continuous with a vessel or represents an underlying lesion, rather than free extravasation
Choroid plexus or vascular calcification Typical location and present on non-contrast imaging
CTA dot sign Intraluminal thrombus in a distal MCA branch in acute ischaemic stroke, not within a haematoma

  1. Peng et al. Predictive Value of CTA Spot Sign on Hematoma Expansion in Intracerebral Hemorrhage Patients. 2017. BioMed research international - Open in new tab. ↩