Noncontrast CT Markers Predict Hematoma Growth Risk in Hemorrhagic Stroke

MRI Brain Hemorrhage
MRI Brain Hemorrhage
Surprisingly, no evidence was found to suggest that patients with these markers benefit from intensive blood pressure reduction.

Noncontrast computed tomography (NCCT) markers identify and stratify hematoma expansion risk in patients with intracerebral hemorrhage (ICH), according to findings from a randomized controlled trial published in Neurology.

Investigators evaluated patient data obtained from the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-II) trial. In this trial, participants were randomly assigned to either intensive (systolic blood pressure <140 mm Hg) or standard (systolic blood pressure <180 mm Hg) blood pressure treatment within a 4.5-hour period from stroke onset.

Several NCCT markers were identified, including intrahematoma hypodensities, swirl sign, black hole sign, blend sign, irregular shape, and heterogeneous hematoma density. Definition of an unfavorable outcome was a 90-day modified Rankin Scale score >3, whereas ICH expansion was defined as a >33% growth in hematoma.

In the total cohort of 989 patients in which baseline images of NCCT scans were available, 21.4% experienced hematoma expansion (n=186/869) and 37.9% experienced an unfavorable outcome (n=361/952). According to the findings, NCCT markers were considered significant independent predictors of ICH expansion (P <.01).

Hematoma density and shape, as well as intrahematoma hypodensity presence, demonstrated higher prediction sensitivity for both ICH expansion and unfavorable outcome. A blend sign, despite its correlation with increased hematoma expansion risk, predicted a good outcome.

Although intensive treatment for BP reduction correlated with reduced ICH expansion risk in hemorrhages with irregular shape, the investigators failed to find an interactive effect between the NCCT expansion predictors and intensive BP reduction (P for interaction >.10).

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Medical complications and infections, which are associated with poor post-ICH outcomes, were not fully accounted for in the final analysis. The investigators were also unable to account for anticoagulant use, which is a “strong predictor of hematoma growth and poor outcome.”

According to the researchers, these results may help determine appropriate risk stratification in patients with ICH and “identify patients with the highest likelihood to benefit from anti-expansion treatment.”


Morotti A, Boulouis G, Romero JM, et al. Blood pressure reduction and noncontrast CT markers of intracerebral hemorrhage expansion. Neurology. 2017;89(6):548-554.