Intracerebral hemorrhage - spot sign

Case contributed by Peter Mitchell
Diagnosis certain


Acute onset left hemiparesis. "Code stroke".

Patient Data

Age: 90 years
Gender: Female

Intraparenchymal cerebral hemorrhage and surrounding edema are centered over the right basal ganglia extending into the frontal and parietal lobes. Intraventricular hemorrhage within the right lateral ventricle, anterior horn of the left ventricle, third ventricle and the aqueduct. Mass effect is seen with partial compression of the body of the right lateral ventricle and midline shift to the left of 4 mm at the level of the septum pellucidum and effacement of the frontal and parietal sulci. Prominence of the temporal horns in keeping with mild-to-moderate hydrocephalus.

Evidence of previous frontal craniotomy, with metallic clips seen medial to the right frontal lobe and encephalomalacia of the parafalcine frontal lobes. Periventricular and deep white matter hypodensity most likely secondary to chronic small vessel ischemia.

Two hyperdense foci are seen within the central portion of the intraparenchymal hematoma on the CTA COW. A 3 x 3 mm posteroinferior projecting right PCOM aneurysm is seen.

Progress CT


The right basal ganglia hemorrhage has significantly increased in size, now having dimensions of 5.5 x 8.8 x 8.2 cm compared to previous dimensions of 4.4 x 4.9 x 4.3 cm. Intraventricular extension into the right lateral, third and fourth ventricles has also mildly progressed.

Progressive mass effect with the previous mild midline shift having increased to 1.5 cm at the level of foramina of Monro. There is now complete effacement of the suprasellar cistern. No tonsillar herniation.

The degree of hydrocephalus of the trapped left lateral ventricle has increased.

Case Discussion

The spot sign is associated with hematoma expansion, and may prove a useful imaging tool to predict those patients who will have clinical deterioration, and may benefit from medical therapies aimed at reducing bleeding risk.

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