By Santosh Murthy, MD

Assistant Professor of Neurology, Weill Cornell Medical College

Dr. Murthy reports no financial relationships relevant to this field of study.

SYNOPSIS: Although the “spot sign” is a predictor of early hematoma expansion, selective treatment of this group with aggressive antihypertensive therapy did not alter hematoma size or neurological outcome.

SOURCE: Morotti A, Brouwers HB, Romero JM, et al.; for the Antihypertensive Treatment of Acute Cerebral Hemorrhage II and Neurological Emergencies Treatment Trials Investigators. Intensive blood pressure reduction and spot sign in intracerebral hemorrhage: A secondary analysis of a randomized clinical trial. JAMA Neurol 2017; June 19. doi:10.1001/jamaneurol.2017.1014. [Epub ahead of print].

Hematoma expansion is a significant predictor of poor outcome in patients with intracerebral hemorrhage (ICH). Therefore, over the past decade, clinical research in ICH has focused on primary injury and hematoma expansion, particularly on early diagnosis and prevention. The “spot sign” present on computed tomographic angiography (CTA) is considered a radiological marker for hematoma expansion, with relatively high predictive accuracy. From the prevention standpoint, intensive blood pressure control has been a long-standing physiological target of interest. However, recent randomized, clinical trials have shown no clinical benefit of aggressive blood pressure reduction in the acute phase of ICH. These results imply that while the early diagnosis of impending hematoma expansion is reasonably accurate, no effective therapeutic intervention exists.

In this study, Morotti et al combined the two approaches mentioned above. They reported the results of a prospective observational study, SCORE-IT (Spot Sign Score in Restricting ICH Growth), which was nested in the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-II) randomized, clinical trial. The objective of the study was two-fold: first, to evaluate the utility of the spot sign in predicting hematoma expansion across different centers, and second, to assess the role of intensive blood pressure reduction in the presence of a CTA-confirmed spot sign. Of the 133 patients with ICH, 53 (39.8%) had a CTA spot sign. Although the spot sign significantly predicted ICH expansion, there was no association between intensive blood pressure control and reduction of hematoma expansion in patients with the spot sign.

COMMENTARY

In light of the acute-phase treatment trials in ICH failing to show a clear clinical benefit, recent studies have used the CTA spot sign to aid the selection of patients who are high-risk for hematoma expansion. For instance, two parallel studies, SPOTLIGHT from Canada and STOP-IT from the United States, explored the role of hemostatic treatment with recombinant factor VII in patients with the spot sign. The pooled analysis validated the predictive ability of the spot sign, but there was no significant association between hemostatic therapy and reduction in hematoma growth or improvement in functional outcomes. A notable limitation of all studies using the CTA spot sign is low statistical power. Although the data consistently affirm the prognostic accuracy of the spot sign, larger studies targeting different physiological mechanisms, such as surgical intervention, may yield success in combating hematoma expansion and improving outcomes of this devastating disease.