Novel Intraoperative and Pathological Findings Related to Computed Tomography Angiography Spot Signs in Intracerebral Hemorrhage Patients: A Case Report.

Introduction: A spot sign on computed tomography angiography (CTA) scan is a widely recognized radiographic indicator of primary intracerebral hemorrhage (ICH) used to predict early hematoma expansion. Nonetheless, recent multicenter studies have indicated that its predictive value for hematoma expansion is not as significant as previously stated. Therefore, identifying the reasons for the poor performance of these studies is imperative.

Case presentation: A 48-year-old man presented with a 9-hour history of alalia and right limb hemiplegia. Noncontrast computed tomography (CT) revealed a hematoma in the left frontal lobe, while CTA showed a spot sign within the hematoma, leading to a diagnosis of frontal lobe hemorrhage. During the surgical procedure, a blood clot was removed, revealing the presence of 3 mm of saccular tissue resembling an aneurysm. The process of exposing its complete form resulted in its rupture and bleeding. The location of this tissue at the top of the hematoma cavity corresponded to the CTA spot sign. Pathological examination confirmed that the characteristics of the tissue wall were consistent with those of a pseudoaneurysm.

Conclusion: This case suggests that more stringent identification criteria should be established in studies predicting ICH expansion using the spot sign on CTA to differentiate and exclude pseudoaneurysms, thereby improving the accuracy of predicting early hematoma expansion using the CTA spot sign.