Black Hole Sign

Intracerebral hemorrhage (ICH) constitutes 10% to 30% of first-ever strokes and is associated with high morbidity and mortality. The reported 30-day mortality of ICH ranges from 30% to 50% and nearly half of the patients died within 2 days after the onset of symptoms. The initial hematoma volume, level of consciousness, and intraventricular extension of bleeding are well-established predictors of functional outcome in patients with ICH. Early hematoma expansion is reported in 19% to 38% of patients with ICH and is associated with poor functional outcome. Identification of useful imaging predictor for hematoma expansion is crucial for therapeutic intervention. The computed tomography angiography (CTA) spot sign is a well-established imaging marker that independently predicts hematoma expansion in patients with ICH. A recent large-scale multicenter observational study suggests that the sensitivity and specificity of CTA spot sign in predicting hematoma expansion were 51% and 85%, respectively. However, early CTA examination requires contrast administration and was contraindicated in patients with several renal function impairment. In addition, CTA spot sign requires immediate admission of CTA examination within the first several hours after onset of symptoms, which was not applicable in many institutions. Therefore, scrutinizing nonenhanced CT scan for possible imaging predictors of hematoma expansion is urgently demanded for patients with ICH. We have identified a new CT-based sign called the black hole sign that may be used as a novel imaging Background and Purpose—Early hematoma growth is a devastating neurological complication after intracerebral hemorrhage. We aim to report and evaluate the usefulness of computed tomography (CT) black hole sign in predicting hematoma growth in patients with intracerebral hemorrhage. Methods—Patients with intracerebral hemorrhage were screened for the presence of CT black hole sign on admission head CT performed within 6 hours after onset of symptoms. The black hole sign was defined as hypoattenuatting area encapsulated within the hyperattenuating hematoma with a clearly defined border. The sensitivity, specificity, and positive and negative predictive values of CT black hole sign in predicting hematoma expansion were calculated. Logistic regression analyses were used to assess the presence of the black hole sign and early hematoma growth. Results—A total of 206 patients were enrolled. Black hole sign was found in 30 (14.6%) of 206 patients on the baseline CT scan. The black hole sign was more common in patients with hematoma growth (31.9%) than those without hematoma growth (5.8%; P<0.001). The sensitivity, specificity, positive predictive value, and negative predictive value of back hole sign in predicting early hematoma growth were 31.9%, 94.1%, 73.3%, and 73.2%, respectively. The time-to-admission CT scan, baseline hematoma volume, and the presence of black hole sign on admission CT independently predict hematoma growth in multivariate model. Conclusions—The CT black hole sign could be used as a simple and easy-to-use predictor for early hematoma growth in patients with intracerebral hemorrhage. (Stroke. 2016;47:1777-1781. DOI: 10.1161/STROKEAHA.116.013186.)