MRI spot sign: Gadolinium contrast extravasation in an expanding intracerebral hematoma on MRI

We report a rare case of gadolinium contrast extravasation in a rapidly expanding basal ganglia hemorrhage on magnetic resonance imaging (MRI). Contrast extravasation within an intracerebral hematoma (ICH) on computed tomography (CT) angiography has been described as the “spot sign” and is a well-known indicator of active bleeding; however, contrast extravasation has seldom been reported on MRI. In this case, a 61-year-old female inpatient developed acute left hemiparesis and dysarthria on her third day of hospital admission. An initial noncontrast head CT showed an ICH, increasing in size on the follow-up CT study, and a subsequent MRI brain without and with contrast demonstrated multiple round collections of active bleeding at the margins of the hematoma on the postcontrast images. A CT angiogram performed following the MRI confirmed contrast extravasation along the margins of the hematoma. This case is unique as it demonstrates the “spot sign” with MRI, and the multiple foci of active bleeding identified with MRI support the “avalanche” hypothesis, which proposes that the initial expanding ICH leads to additional arterial ruptures and propagation of bleeding.