ABSTRACT NUMBER: ESOC2026A1843 ASSOCIATION BETWEEN CEREBRAL VENOUS OUTFLOW IMPAIRMENT, SPOT SIGN AND HEMATOMA EXPANSION IN ACUTE SUPRATENTORIAL INTRACEREBRAL HEMORRHAGE

Abstract Background and aims Venous outflow (VO) is essential for cerebral hemodynamics. Impaired VO has been linked to poor outcome and hemorrhagic transformation in ischemic stroke, but its role in acute intracerebral hemorrhage (ICH) remains understudied. We aimed to investigate its association with spot sign (SS) presence and hematoma expansion (HE) in patients with ICH. Methods We retrospectively included patients admitted to Charité University Hospital, Berlin (January 2019-June 2025) with supratentorial ICH and available baseline CT angiography (CTA). Monophasic CTA was rated for spot sign presence, and VO assessment was performed according to the validated Comprehensive Venous Outflow score. HE was defined as hematoma growth >33%/>6 mL on follow-up imaging. Predictors of SS presence and HE were explored with logistic regression. Results 533 patients were included for SS analysis; 265 (38.2%) underwent follow-up CT and were included in the HE analysis. Median age was 77 years (65–83), and median hematoma volume was 23.7 mL (9.8–62.3). SS was present in 127 (23.8%) patients, and HE occurred in 66 (24.9%). In multivariable logistic regression adjusting for hematoma volume, onset-to-CT time, ICH location, intraventricular hemorrhage, anticoagulants, and systolic blood pressure, impaired VO was associated with SS [aOR for one point decrease in CVO, 0.979, 95%CI 0.960-0.998), and HE in a model that additionally included SS (0.962, 95%CI 0.932-0.994). Conclusions VO impairment may be associated with active bleeding and HE in patients with supratentorial primary ICH. These findings raise the intriguing hypothesis that venous hemodynamics might play a role in the biology of HE. Conflict of interest F. Mazzacane: : nothing to disclose. A. Dell’Orco: : nothing to disclose. B. Del Bello: nothing to disclose. G. Busto: nothing to disclose. E. Fainardi: nothing to disclose. M. Wattjes: nothing to disclose. A. Morotti: nothing to disclose. J. Nawabi: nothing to disclose