Intensive Blood Pressure Reduction and Spot Sign in Intracerebral Hemorrhage

Abstract

Intracerebral hemorrhage (ICH) is still the deadliest type of stroke, with a case fatality rate at 30 days of approximately 40% and severe disability in most of the survivors.¹ Baseline ICH volume is the variable most strongly associated with an unfavorable outcome,² and as many as one-third of patients with ICH experience significant hematoma growth.³ Because of its frequency and association with poor prognosis,⁴ hematoma expansion is an appealing target for acute ICH treatment.⁵ Stratification of ICH expansion risk may help target patients with the highest likelihood to benefit from antiexpansion treatment. An association of the computed tomographic angiography (CTA) spot sign has been found with hematoma growth in a range of single-center studies^6,7 and 1 multicenter study⁸ and may improve our ability to stratify the risk for hematoma expansion in clinical practice. However, different criteria for spot sign definition have been reported, with heterogeneity in spot sign density, dimension, morphologic features, and CTA window. To our knowledge, the diagnostic performance of different spot sign definitions has never been directly compared,⁹ and only 1 spot sign definition was validated in a multicenter study.⁸ In the present study, we investigated whether the CTA spot sign is associated with hematoma growth across a wide range of centers in a large international clinical trial and whether it identifies patients with ICH more likely to benefit from intensive BP reduction. In particular, we tested the hypothesis that intensive BP control would reduce ICH expansion and improve outcome in spot sign–positive patients, whereas those without a spot sign would not benefit from intensive BP reduction. As a secondary analysis, we compared the diagnostic performance of the 2 most commonly used spot sign definitions in the association of hematoma expansion and an unfavorable outcome.