Unusual presentation of more common disease/injury

Case report

Rapidly expanding venous intracerebral haemorrhage
with spot sign
Clark Funnell,1 Manraj K S Heran,2 Philip Teal,1 Thalia Field1
1

Division of Neurology,
University of British Columbia,
Vancouver, British Columbia,
Canada
2
Department of Radiology,
University of British Columbia,
Vancouver, British Columbia,
Canada
Correspondence to
Dr Clark Funnell,
​clark.​funnell@​alumni.​ubc.​ca
Accepted 28 February 2018

Summary
A 79-year-old woman was brought to the hospital
with an acute-onset left haemiparesis. On initial
examination, she had a pure sensorimotor syndrome
with left-sided weakness and sensory disturbance. Her
mental status was normal. She had normal visual fields
to confrontation and no neglect. Her initial CT and CT
angiogram revealed cerebral venous thrombosis with
associated haemorrhage. A ’spot sign’ was visible on
CT angiogram. Immediately following the CT scan,
the patient had a rapidly progressive decline in level
of consciousness, requiring endotracheal intubation. A
follow-up CT scan 70 min later showed the haemorrhage
had expanded dramatically, with mass effect, midline
shift and herniation. After a discussion with the family,
the patient was extubated and died the following day.
This is the first case of a cerebral venous thrombosis with
associated spot sign-positive haemorrhage and published
clinical details that the authors are aware of.

Background

The finding of active contrast extravasation on CT
angiogram in intracerebral haemorrhage (ICH) was
first described in 1999,1 and the term ‘spot sign’
was coined by another group in 2007.2 Spot signs
in primary ICH are thought to be due to ongoing
arterial bleeding causing haemorrhage expansion.3 4

To cite: Funnell C,
Heran MKS, Teal P, et al. BMJ
Case Rep Published Online
First: [please include Day
Month Year]. doi:10.1136/
bcr-2017-223055

Figure 1 (A,B) Selected axial images from a noncontrast CT scan at the time of presentation demonstrate
(A) a small focal haemorrhage in the right mid-frontal
aspect of the centrum semiovale (solid arrow), with
more subtle areas of abnormality immediately posterior
to it, likely representing hyperacute intraparenchymal
blood (asterisk). (B) Low attenuation is seen in the white
matter immediately inferiorly, in the right parietal region,
representing oedema secondary to venous infarction
(dashed arrow).

While a small proportion (2/34) of cases of
secondary ICH due to cerebral venous thrombosis
(CVT) were noted to have a spot sign in a recent
case series,5 the clinical details of the cases were not
published. Haemorrhages associated with veno-occlusive disease are most often described as having
a more indolent clinical course. We are not aware
of the clinical details of a case of haemorrhage due
to CVT with a positive spot sign in the literature;
such a case is presented below. We hypothesise that
a rapidly expanding haematoma, with a venous
spot sign as a radiological correlate, may occur
secondary to sufficiently impaired venous drainage
with associated elevated venous pressure.

Case presentation
The patient was a 79-year-old, right-handed, First
Nations woman evaluated in the emergency department for possible acute stroke.
Her medical history was significant for diverticulosis, iron deficiency anaemia and asthma. There
was no history of deep venous thrombosis, pulmonary embolism or systemic malignancy.
While at home with her daughter, she noted
a sudden-onset numbness in her left leg and foot,
with progression over 1 min up to the left upper
extremity and hand. Her daughter phoned paramedics, and by the time they arrived (15 min after
symptom onset) she had developed left-sided
haemiparesis. At that time, she was noted to be
awake and alert. Her blood pressure was in the
normal range.
The patient arrived at our hospital 30 min
following symptom onset. A brief neurological
exam was performed while the patient was brought
directly from the ambulance stretcher to the CT
scanner. She was alert and appropriately answering
questions. She had mild weakness of the left arm
and leg, being able to lift both against gravity. She
had mild sensory asymmetry with decreased light
touch perception to the left arm and leg compared
with the right.
By the time she was moved out of the CT
scanner (15 min later), she had developed a neglect
syndrome with head and eye deviation towards
the right and progression of the haemiparesis to
complete plegia of the left arm and leg. She did not
blink to visual threat on the left.
Over the next few minutes she became progressively drowsier and was intubated for airway
protection prior to a follow-up CT scan.

Funnell C, et al. BMJ Case Rep 2018. doi:10.1136/bcr-2017-223055

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Unusual presentation of more common disease/injury

Figure 2 Axial source (A) and sagittal maximum intensity projection
(B) images from a CT angiogram (venous phase) performed immediately
after the initial non-contrast CT head examination demonstrate contrast
extravasation, representing a venous ‘spot’ sign, in the areas of obvious
and more subtle haemorrhage (solid arrow), with this seen as a more
extensive site of active bleeding on the sagittal image (dashed arrow).

Investigations

Figures 1–4 demonstrate the initial small haemorrhage, active
extravasation of contrast, and superior and right transverse sinus
thrombosis, as described in the captions. Figures 5–6 demonstrate subsequent expansion of haemorrhage, as described in the
captions.

Differential diagnoses

Imaging studies revealed multifocal venous sinus thrombosis
and intraparenchymal haemorrhage. The differential diagnoses
considered were acute CVT with venous haemorrhage, dural
arteriovenous fistula secondary to chronic CVT, incidental
chronic venous occlusion with primary ICH and coagulopathy
in the context of venous haemorrhage.

Treatment

Given the rapid clinical deterioration, no specific treatment was
initiated. At the time of clinical deterioration, a discussion about
the patient’s wishes was undertaken with her daughter. After
discovery of the hugely expanded haemorrhage, the patient’s
daughter requested palliation only.

Figure 4 Axial source image from CT angiogram performed
immediately after the initial non-contrast CT head examination
demonstrates non-opacification of the right transverse sinus, consistent
with sinus thrombosis (solid arrow).
evidence of dural arteriovenous fistula was seen on post-hoc
review of the images. The presence of associated venous infarction was not consistent with primary ICH. Given the rapid
change in clinical course, coagulation-related blood work was
not drawn prior to palliation. However, previous laboratory
parameters, including international normalized ratio, partial
thromboplastin time and platelets, were normal on the outpatient blood work performed 8 months prior to presentation.
Following discussion with the palliative care service, the
patient was extubated and died the following day.

Outcome and follow-up

The radiological findings were consistent with CVT with associated venous infarction complicated by secondary ICH. No

Figure 3 Selected axial source (A) and sagittal maximal intensity
projection (B) images from a CT angiogram performed immediately
after the initial non-contrast CT head examination demonstrate nonopacification of the superior sagittal sinus distal to the anterior portion
of the sinus, consistent with sinus thrombosis (solid arrows).
2

Figure 5 (A,B) Selected axial images from a non-contrast CT scan
performed approximately 9 min following the initial non-contrast CT
(and following the CT angiogram) demonstrate (A) significant expansion
of intraparenchymal haematoma in the right mid/posterior frontal and
anterior parietal region (solid arrow), with additional development
of an acute falcine subdural haematoma (dashed arrow). (B) Acute
haemorrhage has also now developed in the deeper parenchyma, in the
area of previously identified oedema (asterisk).
Funnell C, et al. BMJ Case Rep 2018. doi:10.1136/bcr-2017-223055

Unusual presentation of more common disease/injury
Learning points
►► The spot sign predicts haematoma expansion in intracerebral

haemorrhage.

►► Cerebral venous thrombosis can rarely be associated with

rapidly expanding intracerebral haemorrhage.

►► A venous spot sign may be seen in intracerebral haemorrhage

associated with cerebral venous thrombosis.

Figure 6 (A,B) Selected axial images from a non-contrast CT scan
performed approximately 70 min following the second non-contrast
CT (after marked clinical deterioration of the patient) demonstrate (A)
massive increase in the amount of intraparenchymal haemorrhage
in the right cerebral hemisphere, with associated effacement of the
adjacent cerebral sulci, and displacement of the falx cerebri left of
midline. Additional uncal and transtentorial herniations were also
present (not shown).

We conclude that elevated venous pressure due to impaired
drainage of the cerebral venous system may be sufficient to result
in rapid haematoma expansion with a venous spot sign.
Contributors CF was involved in the clinical care of the patient and wrote the
manuscript. MKSH edited the manuscript and provided radiological images and
captions. PT was involved in the care of the patient and reviewed the manuscript. TF
edited the manuscript.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Obtained.

Discussion

Provenance and peer review Not commissioned; externally peer reviewed.

CVT occurs most commonly in individuals with underlying
systemic factors promoting a hypercoagulable state. However,
a significant minority of CVTs have no identified cause, with
different series describing 13%–29% of cases as idiopathic.6 7
Approximately one third of patients with CVT have associated
ICH.8 The presence of ICH is associated with a more severe clinical presentation and worse prognosis.
The largest review of CVT with associated haemorrhage identified risk factors for poor outcome, including older age, male
gender, deep cerebral venous system thrombosis, right transverse
venous system thrombosis and presence of a motor deficit. This
woman had several of these risk factors (older age, right transverse sinus involvement, motor deficit). We hypothesise that a
venous spot sign in CVT-associated haemorrhage would be associated with a poorer outcome; however, this requires further
study for confirmation.
The spot sign has generally been described in relation to
arterial sources of active contrast extravasation. Careful review
of the images in this case did not reveal an arterial source of
bleeding.

© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article)
2018. All rights reserved. No commercial use is permitted unless otherwise expressly
granted.

References

1 Becker KJ, Baxter AB, Bybee HM, et al. Extravasation of radiographic contrast is
an independent predictor of death in primary intracerebral hemorrhage. Stroke
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2 Wada R, Aviv RI, Fox AJ, et al. CT angiography "spot sign" predicts hematoma
expansion in acute intracerebral hemorrhage. Stroke 2007;38:1257–62.
3 Dowlatshahi D, Hogan MJ, Sharma M, et al. Ongoing bleeding in acute intracerebral
haemorrhage. Lancet 2013;381:152.
4 Dowlatshahi D, Wasserman JK, Momoli F, et al. Evolution of computed tomography
angiography spot sign is consistent with a site of active hemorrhage in acute
intracerebral hemorrhage. Stroke 2014;45:277–80.
5 Delgado Almandoz JE, Kelly HR, Schaefer PW, et al. CT angiography spot sign predicts
in-hospital mortality in patients with secondary intracerebral hemorrhage. J Neurointerv
Surg 2012;4:442–7.
6	Rodallec MH, Krainik A, Feydy A, et al. Cerebral venous thrombosis and multidetector
CT angiography: tips and tricks. Radiographics 2006;26(Suppl 1):S5–S18.
7 Gosk-Bierska I, Wysokinski W, Brown RD, et al. Cerebral venous sinus thrombosis:
Incidence of venous thrombosis recurrence and survival. Neurology 2006;67:814–9.
8 Girot M, Ferro JM, Canhão P, et al. Predictors of outcome in patients with cerebral
venous thrombosis and intracerebral hemorrhage. Stroke 2007;38:337–42.

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Funnell C, et al. BMJ Case Rep 2018. doi:10.1136/bcr-2017-223055

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