1. post contrast CT extravasation is associated with hematoma expansion in CTA spot negative patients A Ederies, A Demchuk, T Chia, et al Stroke 2009;40:1572-1576

2. Day 1 Day 2 SAH, ICH routine CTA - look for cause discovery: CTA spot sign predicts hematoma expansion Wada, Aviv et al. Stroke 2007 38:1257

3. CTA-SICT post Cor MIP CTA Spot Sign Wada, Aviv et al. Stroke 2007;38:1257 Gazzola, Aviv et al Stroke 2008;39:1177 13/39 enhancing foci 13/39 enhancing foci 11 pts  more bleeding 10 spot sign, 1 no 11 pts  more bleeding 10 spot sign, 1 no stop light & stop it studies

4. post contrast CT extravasation is associated with hematoma expansion in CTA spot negative patients A Ederies, A Demchuk, T Chia, et al Stroke 2009;40:1572-1576

5. Introduction early hematoma growth and neurological deterioration → increased mortality contrast extravasation (CE) correlates with hematoma growth CTA spot sign: marker of hematoma expansion some hematomas enlarge without + CTA spot sign reducing diagnostic performance for expansion prediction

6. PCCT 24 hr NCCT NCCTCTA PCT extravasation remote from or in absence of spot sign new term: post contrast leakage/extravasation PCL

7. Hypothesis: PCL (post contrast leakage): high risk of hematoma expansion in CTA spot negative hematomas PCL impacts little where CTA spot sign already positive PCL is not an “artifact” of CTA by imaging too early

8. Methods prospective ICH patient data, 2004-08, retrospective analysis inclusion criteria: ICH with CTA and/or CTP ≤6 hours follow up within 24 hrs 85 cases excluded: 14 >6 hrs, 7 surgery, 3 no follow up 61 final cohort

9. patients groups group A CTA spot +ve group B CTA spot -ve blinded hematoma volume estimate ABC/2 expansion >30% or 6ml IVH not considered scan time stamp CTA and PCCT (post contrast CT) mid-hematoma level Methods PCL +ve/ -ve

10. Results 64±15 yrs; 67% M no clinical baseline differences grp A vs B group A 34% (21/61); group B 40/61 PCL 18% (11/61) 6/21 in + spot sign 5/40 in – spot sign PCL +ve 12.5% (5/40) but - CTA spot sign

11. Results group A: PCL +ve Higher baseline Volume CTA spot positive (Group A) n=21 PCL (n=6) No PCL (n=15) P value initial vol cm 3 60.00±43.0625.04±22.470.04* final volume cm 3 81.29±48.5336.37±26.080.07 vol change cm 3 14.47±8.4111.32±23.410.07 vol change % 25.80±15.1924.61±17.190.97

12. Results group A: trend to larger final, absolute volume change 4/6 PCL+ve underwent expansion (67%) PCL contributes to, but overshadowed by CTA spot +ve CTA spot positive (Group A) n=21 PCL (n=6) No PCL (n=15) P value initial vol. cm 3 60.00±43.0625.04±22.470.04* final volume cm 3 81.29±48.5336.37±26.080.07 vol. change cm 3 14.47±8.4111.32±23.410.07 vol. change % 25.80±15.1924.61±17.190.97

13. Results group B: larger absolute and % volume change mean change PCL +ve 5ml and 26% 3/5 PCL underwent expansion (60%) 3/40 (8%) GRP B expansion missed by excluding PCL extravasation CTA Spot negative (Group B) n=40 PCL (n=5) No PCL (n=35) P value initial volume cm 3 19.94±14.3029.68±34.160.98 final volume cm 3 25.17±19.1327.86±34.550.58 volume change cm 3 5.23±5.74-1.54±6.440.02† volume change %25.91±17.36-0.07±23.860.02†

14. Results group A larger initial, final & abs volume growth vs group B suggests effect of PCL overshadowed if CTA spot sign +ve CTA spot + (Group A) n=21 PCL (n=6) CTA Spot - (Group B) n=40 PCL (n=5) PCL Group A vs B initial vol cm 3 60.00±43.06 19.94±14.300.02‡ final volume cm 3 81.29±48.53 25.17±19.130.03‡ vol change cm 3 14.47±8.41 5.23±5.740.03‡ vol change % 25.80±15.19 25.91±17.360.54

15. PCL excluded Sensitivity: 0.78 (0.5-0.9) Specificity: 0.84 (0.69-0.93) NPV: 0.90 (0.76-0.97) PPV: 0.67 (0.43-0.85) diagnostic performance predicting expansion PCL included 0.94 (0.72-1.00) 0.79 (0.64-0.90) 0.97 (0.85-1.00) 0.65 (0.44-0.83)

16. time from CTA smart prep trigger to mid- hematoma not different PCL 27±13 vs no PCL 32±11; p=0.2 PCL and time

17. Conclusion:  risk of hematoma expansion, group B PCL +ve 9% expanding lesions missed without PCT effects of PCL overshadowed by Spot + higher initial, final & absolute volume (grp A vs B PCL +ve) cumulative effect of spot sign & PCL (Grp A) non opacification of CTA spot - not time related

18. so what? potentially powerful tool stop light trial STOP IT (USA) & stoplight (Canada) studies CTA only - no PCCT 9% lesions ? effect on primary outcome different etiologies – Miller Fisher primary vs secondary arterial vs venous

19. Acknowledgement stroke team and CT technicians Sunnybrook Health Sciences Centre renewed interest in intracerebral hemorrhage because of CTA and C-CT: Stoplight, Stop It Trials