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

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 computed tomography (NCCT) hypodensity and computed tomography 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 multicenter 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 (⩾6 mL or ⩾33%) and severe HE (⩾12.5 mL 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 (interquartile range (IQR) = 6.4–40) vs 3.2 mL (IQR= 0–23.3), p = 0.018), and hematoma relative growth (92% (IQR = 16–151%) vs 24% (IQR= 0–69%), p = 0.038). There was a strong association between B&W sign and HE (adjusted odds ratio (OR) = 7.83 (95% confidence interval (CI) = 2.93–20.91)) and severe HE (adjusted OR = 5.67 (95% CI = 2.41–13.36)). The B&W sign yielded a positive predictive value of 79.3% (IQR = 61.7–90.1) for HE. Inter-rater agreement was moderate (k = 0.54). Conclusion: The B&W sign is associated with an increased likelihood of HE and severe HE by approximately eightfold and fivefold, respectively.