What does the CT angiography "spot sign" of intracerebral hemorrhage mean in modern neurosurgical settings with minimally invasive endoscopic techniques?

Hematoma expansion is correlated with morbidity and mortality for patients with intracerebral hemorrhage (ICH). Recent studies demonstrated that contrast extravasation on contrast-enhanced CT and small-enhancing foci, so-called spot signs, on CT angiography are associated with subsequent hematoma enlargement. Such radiological markers of ICH may have significant implications not only as a surrogate marker for hematoma expansion in medical hemostatic therapy but also as indication for surgery. In this article, a brief description of contrast extravasation and "spot sign" will be provided first. The findings of some of the important trials that shaped the current landscape of therapeutic interventions for ICH will then be reviewed. Many neurosurgeons have faced a significant dilemma since the Surgical Trial in Intracerebral Haemorrhage (STICH) trial was published. Under adverse circumstances, many neurosurgeons assume that minimally invasive surgical interventions are still likely to benefit some patients and will be more effective. Among future candidate strategies for ICH, the most promising is neuroendoscopic surgery with direct hemostatic devices, which attains direct local hemostasis at the sites of vascular rupture. It is plausible that ultra-early direct hemostatic surgery given in the emergency setting might reduce hematoma volume and rebleeding and improve outcome. Finally, a description of future avenues of minimally invasive surgery for ICH treatment and suggestions for the design of further studies using reliable predictor of hematoma expansion spot sign will be provided. Neuroendoscopic interventions are minimally invasive and are likely of benefit in hemostasis and hematoma removal. On the basis of these observations, the spot sign of ICH has sub-emergency surgical implications.