Ongoing intracerebral bleeding despite hemostatic treatment associated with a spot sign in a patient on oral anticoagulation therapy.

Stroke Notes nial CT at 09: 43 revealed an ICH of 17 ml volume (fig. 1 a). We immediately administered 1,500 units of prothrombin complex concentrates (PCC) within 15 min. However, despite an INR of 1.5 the patient deteriorated within 1 h. CT at 10: 59 revealed an expansion of the hematoma to a volume of 84 ml (fig. 1 b). At this time, we also detected a spot sign within the hemorrhage on CTA source images (fig. 1 c). The PCCT, which was performed 2 min after CTA, revealed massive enlargement of this hyperintense area to more than tenfold of the primary spot sign (0.15–1.67 ml) (fig. 1 d). At 20: 30, CT revealed further expansion of the hemato-ma to a volume of 99 ml (fig. 1 e). The patient died 35 h after the onset of symptoms. Discussion The spot sign occurred in about 1/3 of patients with spontaneous ICH in a smaller prospective study [4]. Primary and secondary vessel injuries are discussed as being the reason for the occurrence of the spot sign [4–6]. Wada et al. [4] studied spot signs for the presence or absence of contrast extravasation and described them as enlarging in PCCT. Contrast extravasation on PCCT was found especially in patients on OAC [4, 5, 7] , but no significant difference in final volume or change of volume of the spot signs with extravasation in contrast to spot signs without extravasation was found [4]. It thus remains unclear whether extravasation on PCCT represents only leakage of contrast medium or ongoing bleeding or both. Our patient was on OAC, which probably amplifies the risk of hematoma enlargement [2]. We saw massive enlargement of the extravasation within 2 min and hematoma enlargement on follow up CT, despite immediate reversal of the anticoagulatory effect to an INR of 1.5. These radiographic findings are suggestive of primary vessel injury and ongoing bleeding in this case. Introduction In spontaneous intracerebral hemorrhage (ICH) hematoma size is known to be one of the most important predictors of 30-day mortality and hematoma expansion is an independent predictor of mortality and functional recovery [1]. Especially ICH patients on oral anticoagulation (OAC) are at risk of increase in hematoma size [2]. Reliable radiographic predictors of ICH growth do not exist [3]. The presence of spot signs was found to be associated with hematoma expansion and poor clinical outcome [4–7]. Spot signs are defined …