Ten signs of enlarged cerebral hemorrhage hematoma in CT images (top)

According to the World Health Organization, stroke has become the second most common cause of death worldwide, with more than 5.
78 million people dying of stroke every year, with an average of one person dying
every 5 seconds.

According to the latest guidelines, all patients admitted to hospital with suspected acute stroke should have brain imaging evaluation
upon arrival at the hospital.
In most cases, noncontrast CT (NCCT) can provide the necessary information
for emergency department evaluation.
(I, B-NR, adapted from the 2013 version of the guide)

2018 American Stroke Association/American Heart Association guidelines for the early management of patients with acute ischemic stroke.
Chinese Journal of Cerebrovascular Diseases, 2018, v.
15(05):48-62.

Cerebral hemorrhage (cerebral hemorrhage) refers to non-traumatic bleeding caused by vascular rupture in the brain parenchyma, accounting for 20%~30% of all strokes, although the proportion of stroke patients is not high, but the mortality rate of cerebral hemorrhage in the acute stage is 30%~40%, most of the deaths occur within two weeks of onset, and most of the survivors have different degrees of dyskinesia, cognitive impairment, speech swallowing disorders and other sequelae
.

As an essential technique for stroke examination, CT non-contrast scan can not only distinguish ischemic stroke from hemorrhagic stroke, but also have some subtle signs that can predict whether intracerebral hemorrhage will expand, which is helpful
for determining treatment plan and prognosis.

Let's take a look at how to tell if the cerebral hemorrhage will expand
on non-contrast CT scanning.

Irregular margins and mixed density signs of hematoma

In 2009, Barras et al.
divided hematomas into two types of 5 types according to shape and density, as shown in the figure below (shape classification on the left and density classification on the right):

Representative scan planes described by Barras' classification criteria showed grade 5 mixed density signs (A) and hematoma margin irregularities (B), and A5 showed the presence of fluid levels
.

Statistical analysis found that mixed density signs and margin irregularities using plain scan CT were associated
with 24-hour haematoma expansion.
These markers may help predict results in the absence of CT angiography and may help further refine the predictive value
of CT angiography signs.

Blend Sign

Mixed density sign is a sign proposed by Chinese scholars to predict the expansion of cerebral hemorrhage
.

Non-contrast CT scan shows mixed density signs and mixed differential diagnostic maps
.
Axial CT non-contrast scan images
of 4 patients with CT mixed density sign and suspected mixed density sign.
A and B, manifestations of mixed density signs of different forms of CT in patients with intracerebral hemorrhage
.
Note that the mixed density sign consists of two parts, and the CT values are significantly different
.
There is a clear boundary
between these two areas.
C, uneven-looking putamenatoma with no clear edge
between high-density and relatively low-density areas.
D, a low-density area within a high-density hematoma, consistent
with the CT vortex sign.

Black Hole Sign

Black hole signs can predict the enlargement
of cerebral hematomas.
This is an imaging index based on CT that can independently predict hematoma enlargement, which improves the applicability and ease of use of punctate signs, and has a specificity of 94.
1%
for predicting early hematoma enlargement.

Black hole sign is a strict criterion for judging the degree of unevenness of CT values, which improves the reliability and objectivity of the previous hematoma inhomogeneity judgment, and for medical institutions that cannot carry out early CTA examination, CT-based non-contrast scanning can also predict the early hematoma enlargement
of patients with cerebral hemorrhage.

Black hole markers (A-D)
on CT images on admission.
Irregular black hole sign (indicated by arrows)
in patients with putamenic hemorrhage.
NOTE THAT THERE IS A RECOGNIZABLE EDGE BETWEEN THE LOW-ATTENUATION BLACK HOLE AND THE ADJACENT HEMATOMA, AND THE DIFFERENCE IN CT VALUES BETWEEN THE TWO DENSITIES IS 35 HU.

B, a circular black hole sign with a clear contrast between the low-density region and the adjacent high-density hematoma (indicated by the arrow).

C, the sign of a black hole may be rod-shaped (arrow).

Note that the poorly differentiated zone is contained within the hematoma and is not associated
with adjacent brain tissue.
D, a small circular black hole (arrow)
inside the hematoma.

Differential diagnosis of black hole signs:

A.
Uneven low-density hematoma with no obvious boundaries (arrows).

B, the low-density zone (arrowhead) is located within the
high-density hematoma.
There is a recognizable boundary
between two density regions.
However, the difference in CT value is ≈20 HU.

C, there are 3 rod-shaped low-intensity areas (arrows)
around the hematoma.
However, the low-density area is connected to adjacent brain tissue and is not completely encased in the
hematoma.
D, a black dot (arrow)
with a blurred border.

Swirl sign

The low-density or isodensity areas in the high-density area of the hematoma have a variety of shapes, which can be round, strip-shaped, or irregular shapes
.
It is more common in patients with known poor prognosis such as midline displacement and bleeding into the ventricle, and its incidence is closely related to the size of the hematoma (5-30ml: 41%, >30ml: 62%, P=0.
01; only 6% of patients with 1-4ml of bleeding have vortex sign), suggesting that vortex sign may be a marker
for predicting hematoma enlargement.

Diagnosis and differential diagnosis of vortex sign:

Axial images
of 6 patients with different ICH.
(a-c) show different forms of vortex signs; A is well-defined, B is irregular, and C is strip-shaped
.
(e) shows right-sided subacute frontal hemorrhage with low outer posterior density (black arrow), indicating that the hematoma is beginning to absorb (clot contraction) and should not be considered a vortex sign
.
(f) shows left subacute frontal hemorrhage with multiple fluid levels (short arrows) and should not be considered a vortex sign.

Satellite sign

The study found that the presence of satellite signs on the initial CT scan was associated
with a significant deterioration in functional outcomes in patients with intracerebral hemorrhage.

CT illustration
with satellite sign (A-C) and without satellite sign (D).
Non-contrast axial CT images
of different patients.
We define the satellite sign as a small (maximum diameter < 10 mm) hemorrhage (arrow) that is close to at least one level but completely isolated
from the main hemorrhage.
The minimum distance between the satellite and the main hemorrhage is 1-20 mm
.

a.
"Satellite sign" shown in NCCT and "point sign" shown in CTA; b.
Satellite sign (+) and point sign (-)

The satellite sign was found to be an independent predictor of the enlargement of
spontaneous intracerebral hemorrhage.
Although the point sign has high predictive accuracy, the satellite sign remains an acceptable predictor
of hematoma enlargement when CTA is not available.

Island Sign

The island conquest was proposed
by Chinese scholars.

Schematic map
of the island.
Axial CT non-contrast scan images
of 4 patients with CT island sign.
A.
CT island sign
in patients with basal ganglia hemorrhage.
Note that there are 3 small scattered small hematomas (arrowheads), each separate from
the main hematoma.
B, intraputamen hemorrhage, with 3 small separate hematomas (arrowheads).

Note that there are low-density areas
between the 3 small hematomas and the major hematoma.
C, cerebral hemorrhage hematoma, 4 scattered independent hematomas (arrows).

D, massive hemorrhage in the basal ganglia, rupture into the ventricles
.
The hematoma consists of 4 vesicular or bud-shaped small hematomas (arrowheads), connected to the main hematoma, and a separate small hematoma (arrowheads).

Island signs and differential diagnosis
.

CT image
of a patient with a positive island sign.
Note 3 scattered small hematomas (arrowheads), each separate from
the main hematoma.
The main hematoma consists of
4 lobes.
B, irregularly shaped putamen hematoma
.
The hematoma is lobulated (arrowhead), and the lobules do not consider the island sign.

Note that tiny points of intracerebral hemorrhage (arrows) should not be considered isolated hematomas
.
C, putamen hemorrhage, 2 scattered small hematomas (indicated by arrows).

Note that the irregular edges (arrows) of the major hematoma are not considered insular signs
.
D, basal ganglion hematoma, with 2 leaflets (arrowheads).

The lobules of the primary hematoma are not considered insular signs
.

The
difference between the shape ratio of Barras and Li Qi Island Sign.
A, Barras grade IV hematoma
.
Note that the irregular margins have a broad base, and the border of the primary hematoma is spike-shaped (arrowhead).

B, a lobulated hematoma, belongs to Barras
grade five.
Note that the hematoma consists of
4 spike-like projections (lobules).
C.
The insular sign consists of a separate islet (arrowhead) and 3 islets (arrowhead) that are connected to
the major hematoma.
Note that the 3 small hematomas are vesicular or bud-like
that flow from the main hematoma.
D, a large hematoma with 4 vesicular or bud-like small hematomas (arrowheads), all associated
with major bleeding.
Note that the large and small lobes (large arrowheads) at the base of the major hematoma are not considered island-shaped
.

Liquid level

The presence of this sign can reflect abnormalities in the blood clotting process, which leads to early HDL deposition
.
During the coagulation of hematomas, uncoagulated blood (plasma) is deposited first, and clotting blood clots are subsequently deposited, which leads to this precipitation phenomenon, which is manifested as a fluid level, which often reflects inadequate
hemostasis.
For patients with coagulopathy, the prothrombin time and partial thromboplastin time are abnormal, and the fluid level after bleeding is high
.

Stroke patients generally routinely undergo non-contrast CT scanning, and it is very helpful
to evaluate the enlargement of the hematoma through information such as the morphological density of the hematoma in the non-scan image.
If possible, enhancement examination can also be performed, and next time we will continue to share the predictive value
of enhanced CT images for hematoma enlargement.