Validation of the Black-&-White sign to predict intracerebral hematoma expansion in the multi-center PREDICT study cohort.

Abstract

Background: Hematoma expansion (HE) occurs in one-fourth to one-third of patients with acute intracerebral hemorrhage (ICH) and is associated with worse outcomes. The co-localization of non-contrast CT (NCCT) hypodensity and CT angiography (CTA) spot sign, the so-called Black-&-White (B&W) sign, has been shown to have high predictive accuracy for HE in a single-center cohort. In this analysis, we aimed to validate the predictive accuracy of the B&W sign for HE in a multi-center cohort.

Methods: Acute ICH patients from the multicenter, observational PREDICT study (Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT) were included. Outcomes included HE (≥6mL or ≥33%) and severe HE (≥12.5mL or >66%). The association between B&W sign and outcomes was assessed with multivariable regression analyses adjusted for baseline factors.

Results: Three hundred four patients were included, with 106 (34.9%) showing HE. The spot sign was present in 76 (25%) patients, the hypodensity sign in 119 (39.1%), and the B&W sign in 29 (9.5%). In the stratum with positive spot signs, patients with B&W signs experienced more frequent HE (79.3% vs. 46.8%, p=0.008), hematoma absolute growth (19.1 mL [IQR=6.4-40] vs. 3.2 mL [0-23.3], p=0.018), and hematoma relative growth (92% [IQR=16-151%] vs. 24% [0-69%], p=0.038). There was a strong association between B&W sign and HE (adjusted OR 7.83 (95%CI=2.93-20.91) and severe HE (adjusted OR 5.67 (95%CI=2.41-13.36). The B&W sign yielded a PPV of 79.3% (IQR=61.7-90.1) for hematoma expansion. Inter-rater agreement was moderate (k=0.54).

Conclusion: The Black-&-White sign is associated with an increased likelihood of HE and severe HE by approximately eightfold and fivefold, respectively.