The “connecting vessel” sign: an imaging biomarker to differentiate ruptured infected (mycotic) intracranial aneurysm mimicking the CTA spot sign
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Infected (mycotic) intracranial aneurysms (IIA) are a prevalent source of morbidity in patients with systemic infection. Unlike saccular aneurysms, ruptured IIA frequently presents with intracerebral hemorrhage (ICH), and the appearance of ruptured IIA on CTA overlaps with the CTA “Spot Sign” (SS), an imaging finding in non-infectious, spontaneous ICH. The purpose of this study was to investigate the imaging and clinical features which may differentiate these two entities on CTA for which treatment strategies differ substantially.
In an IRB-approved, retrospective case series, we compared 14 patients with confirmed IIA and 14 patients with positive SS due to other non-infectious etiology (SS(+) ICH). Clinical history, laboratory studies, and CTA reports and images were reviewed to define imaging characteristics of IIA and SS(+) ICH, including the diagnostic criteria for SS used in clinical trials.
A total of 7/14 patients (50.0%) diagnosed with IIA had ICH at presentation. Of these, 3/7 patients (42.9%) with ruptured IIA and ICH met diagnostic imaging criteria of SS. The remaining 4/7 patients did not meet criteria due to presence of a connecting vessel. Compared with SS(+) ICH of non-infectious etiology, patients with ruptured IIA were younger (40.7 vs. 66.4 years) and had higher rates of IVDU and bacteremia (p < 0.01) and lower rates of hypertension (p < 0.01). Hematoma volume was similar in both groups, but lobar location was more frequent in ruptured IIA (p = 0.06). Mortality at 1 year from diagnosis was equally high in both groups (42.9%).
This study characterizes ruptured IIA as an imaging mimic of SS and provides a framework for differentiating these lesions, allowing prompt diagnosis and appropriate treatment.
KeywordsIntracerebral hemorrhage Intraparenchymal hemorrhage Infected intracranial aneurysm Mycotic aneurysm Stroke CTA Spot sign
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
- 5.Wada R, Aviv RI, Fox AJ, Sahlas DJ, Gladstone DJ, Tomlinson G, Symons SP (2007) CT angiography “spot sign” predicts hematoma expansion in acute Intracerebral hemorrhage. Stroke 38:1257–1262. https://doi.org/10.1161/01.STR.0000259633.59404.f3 CrossRefPubMedGoogle Scholar
- 8.Fennell VS, Kalani MYS, Atwal G et al (2016) Biology of saccular cerebral aneurysms: a review of current understanding and future directions. Front Surg 3. https://doi.org/10.3389/fsurg.2016.00043
- 10.Allen LM, Fowler AM, Walker C, Derdeyn CP, Nguyen BV, Hasso AN, Ghodke BV, Zipfel GJ, Cross DT 3rd, Moran CJ (2013) Retrospective review of cerebral mycotic aneurysms in 26 patients: focus on treatment in strongly immunocompromised patients with a brief literature review. Am J Neuroradiol 34:823–827. https://doi.org/10.3174/ajnr.A3302 CrossRefPubMedGoogle Scholar
- 12.Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, de Ferranti SD, Floyd J, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Mackey RH, Matsushita K, Mozaffarian D, Mussolino ME, Nasir K, Neumar RW, Palaniappan L, Pandey DK, Thiagarajan RR, Reeves MJ, Ritchey M, Rodriguez CJ, Roth GA, Rosamond WD, Sasson C, Towfighi A, Tsao CW, Turner MB, Virani SS, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P, American Heart Association Statistics Committee and Stroke Statistics Subcommittee (2017) Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation 135:e146–e603. https://doi.org/10.1161/CIR.0000000000000485 CrossRefPubMedPubMedCentralGoogle Scholar
- 13.Hanley DF, Thompson RE, Rosenblum M, Yenokyan G, Lane K, McBee N, Mayo SW, Bistran-Hall AJ, Gandhi D, Mould WA, Ullman N, Ali H, Carhuapoma JR, Kase CS, Lees KR, Dawson J, Wilson A, Betz JF, Sugar EA, Hao Y, Avadhani R, Caron JL, Harrigan MR, Carlson AP, Bulters D, LeDoux D, Huang J, Cobb C, Gupta G, Kitagawa R, Chicoine MR, Patel H, Dodd R, Camarata PJ, Wolfe S, Stadnik A, Money PL, Mitchell P, Sarabia R, Harnof S, Barzo P, Unterberg A, Teitelbaum JS, Wang W, Anderson CS, Mendelow AD, Gregson B, Janis S, Vespa P, Ziai W, Zuccarello M, Awad IA, MISTIE III Investigators (2019) Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial. Lancet 393:1021–1032. https://doi.org/10.1016/S0140-6736(19)30195-3 CrossRefPubMedGoogle Scholar
- 14.Radmanesh F, Falcone GJ, Anderson CD, Battey TW, Ayres AM, Vashkevich A, McNamara K, Schwab K, Romero JM, Viswanathan A, Greenberg SM, Goldstein JN, Rosand J, Brouwers HB (2014) Risk factors for computed tomography angiography spot sign in deep and lobar intracerebral hemorrhage are shared. Stroke 45:1833–1835. https://doi.org/10.1161/STROKEAHA.114.005276 CrossRefPubMedPubMedCentralGoogle Scholar
- 18.Delgado Almandoz JE, Yoo AJ, Stone MJ, Schaefer PW, Goldstein JN, Rosand J, Oleinik A, Lev MH, Gonzalez RG, Romero JM (2009) Systematic characterization of the computed tomography angiography spot sign in primary intracerebral hemorrhage identifies patients at highest risk for hematoma expansion: the spot sign score. Stroke 40:2994–3000. https://doi.org/10.1161/STROKEAHA.109.554667 CrossRefPubMedPubMedCentralGoogle Scholar
- 19.Thompson AL, Kosior JC, Gladstone DJ, Hopyan JJ, Symons SP, Romero F, Dzialowski I, Roy J, Demchuk AM, Aviv RI, PREDICTS/Sunnybrook ICH CTA Study Group (2009) Defining the CT angiography ‘spot sign’ in primary Intracerebral hemorrhage. Can J Neurol Sci 36:456–461. https://doi.org/10.1017/S0317167100007782 CrossRefPubMedGoogle Scholar
- 25.de Jong JP, Kluijtmans L, van Amerongen MJ et al (2017) “On the spot”: the use of four-dimensional computed tomography angiography to differentiate a true spot sign from a distal intracranial aneurysm. World Neurosurg 105:1037.e9–1037.e12. https://doi.org/10.1016/j.wneu.2017.06.046 CrossRefGoogle Scholar
- 29.Auer RN, Sutherland GR (2005) Primary intracerebral hemorrhage: pathophysiology. Can J Neurol Sci 32(Suppl 2):S3–S12Google Scholar
- 31.Roh D, Sun C-H, Murthy S, Elkind MSV, Bruce SS, Melmed K, Ironside N, Boehme A, Doyle K, Woo D, Kamel H, Park S, Agarwal S, Connolly ES, Claassen J (2019) Hematoma expansion differences in lobar and deep primary intracerebral hemorrhage. Neurocrit Care 31:40–45. https://doi.org/10.1007/s12028-018-00668-2 CrossRefPubMedGoogle Scholar
- 32.Brouwers HB, Chang Y, Falcone GJ, Cai X, Ayres AM, Battey TW, Vashkevich A, McNamara K, Valant V, Schwab K, Orzell SC, Bresette LM, Feske SK, Rost NS, Romero JM, Viswanathan A, Chou SH, Greenberg SM, Rosand J, Goldstein JN (2014) Predicting hematoma expansion after primary intracerebral hemorrhage. JAMA Neurol 71:158–164. https://doi.org/10.1001/jamaneurol.2013.5433 CrossRefPubMedPubMedCentralGoogle Scholar
- 34.Falcone GJ, Biffi A, Brouwers HB, Anderson CD, Battey TW, Ayres AM, Vashkevich A, Schwab K, Rost NS, Goldstein JN, Viswanathan A, Greenberg SM, Rosand J (2013) Predictors of hematoma volume in deep and lobar supratentorial intracerebral hemorrhage. JAMA Neurol 70:988–994. https://doi.org/10.1001/jamaneurol.2013.98 CrossRefPubMedGoogle Scholar
- 37.Dowlatshahi D, Wasserman JK, Momoli F, Petrcich W, Stotts G, Hogan M, Sharma M, Aviv RI, Demchuk AM, Chakraborty S, Ottawa Stroke Research Group (2014) Evolution of computed tomography angiography spot sign is consistent with a site of active hemorrhage in acte intracerebral hemorrhage. Stroke 45:277–280. https://doi.org/10.1161/STROKEAHA.113.003387 CrossRefPubMedGoogle Scholar
- 38.Sorimachi T, Osada T, Baba T, Inoue G, Atsumi H, Ishizaka H, Hotta K, Hayashi N, Matsumae M (2013) The striate artery, hematoma, and spot sign on coronal images of computed tomography angiography in putaminal intracerebral hemorrhage. Stroke 44:1830–1832. https://doi.org/10.1161/STROKEAHA.113.001498 CrossRefPubMedGoogle Scholar
- 39.Orito K, Hirohata M, Nakamura Y, Takeshige N, Aoki T, Hattori G, Sakata K, Abe T, Uchiyama Y, Sakamoto T, Morioka M (2016) Leakage sign for primary intracerebral hemorrhage: a novel predictor of hematoma growth. Stroke 47:958–963. https://doi.org/10.1161/STROKEAHA.115.011578 CrossRefPubMedPubMedCentralGoogle Scholar
- 40.Walkoff L, Brinjikji W, Rouchaud A, Caroff J, Kallmes DF (2016) Comparing magnetic resonance angiography (MRA) and computed tomography angiography (CTA) with conventional angiography in the detection of distal territory cerebral mycotic and oncotic aneurysms. Interv Neuroradiol 22:524–528. https://doi.org/10.1177/1591019916653247 CrossRefPubMedPubMedCentralGoogle Scholar
- 41.Park SM, Han YM, Park YS et al (2005) Acute aneurysmal subdural hematoma: clinical and radiological characteristics. J Korean Neurosurg Soc 37:329–335Google Scholar
- 42.Zanaty M, Chalouhi N, Starke RM, et al (2013) Endovascular treatment of cerebral mycotic aneurysm: a review of the literature and single center experience. In: BioMed Research International. https://www.hindawi.com/journals/bmri/2013/151643/. Accessed 14 Aug 2018