CT predictors of intracerebral hemorrhage expansion

Last revised by Dr Khalid Alhusseiny on 24 Jun 2022

Intracerebral hemorrhage (ICH) is a type of cerebrovascular stroke that represents an unfortunate consequence of cerebral small vessel disease and is associated with high early mortality. Certain CT markers can be used to predict intracerebral hemorrhage expansion which can help identify patients at higher risk of hemorrhage growth to improve management outcomes.

Noncontrast CT

  • Hemorrhage size

The volume of an intracerebral hemorrhage can be measured using ABC/2 formula or 3D volumetric software. It is considered to be the most reliable independent predictor of ICH expansion. Hematoma expansion is measured as an increased growth >12.5 ml or volume >33% from initial CT scan. Hematomas with volume more than 30 ml are more prone to expansion.

  • Hemorrhage shape

Intracerebral hemorrhage irregularity is thought to be due to multiple leaking vessels feeding the hematoma. Hemorrhages with irregular shape are more prone to expansion.

  • Hemorrhage density

The presence of hypodense or isodense regions within the hyperdense intracerebral hemorrhage represents active bleeding and called swirl sign. When the swirl sign is encapsulated it is termed black hole sign. Heterogeneous hemorrhage with hypodense foci is more prone to expansion.

  • Intraventricular hemorrhagic extension

Intraventricular hemorrhagic extension occurs due decompression of the hemorrhage into the low resistance ventricular system, thus; hematomas located in thalamus, caudate nucleus or pons are more prone to intraventricular extension than lobar hematomas. A study has shown that lenticular and lobar hematomas with accompanying intraventricular extension displayed a higher proportion of hematoma expansion2.

Contrast CT

Active contrast extravasation within hematoma predicts future hemorrhage expansion. This can be observed on CT angiography (CTA) as spot sign and pooling of contrast within the hematoma.


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Cases and figures

  • Intracerebral hemorrhage - spot sign
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