Arosh S Perera Molligoda Arachchige, MD, Faculty of Medicine, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele 20072, Lombardy, Italy. aroshperera@outlook.it
Research Domain of This Article
Radiology, Nuclear Medicine & Medical Imaging
Article-Type of This Article
Letter to the Editor
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Radiol. Oct 28, 2025; 17(10): 114449 Published online Oct 28, 2025. doi: 10.4329/wjr.v17.i10.114449
Toward rapid, practical risk stratification in spontaneous intracerebral hemorrhage
Arosh S Perera Molligoda Arachchige
Arosh S Perera Molligoda Arachchige, Faculty of Medicine, Humanitas University, Pieve Emanuele 20072, Lombardy, Italy
Author contributions: Perera Molligoda Arachchige AS reviewed and endorsed the final manuscript.
Conflict-of-interest statement: The author reports no relevant conflicts of interest for this article.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Arosh S Perera Molligoda Arachchige, MD, Faculty of Medicine, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele 20072, Lombardy, Italy. aroshperera@outlook.it
Received: September 19, 2025 Revised: October 3, 2025 Accepted: October 21, 2025 Published online: October 28, 2025 Processing time: 39 Days and 6.4 Hours
Abstract
Spontaneous intracerebral hemorrhage carries high early mortality and long-term disability, with hematoma expansion (HE) being the most important modifiable determinant of poor outcome. Although the computed tomography (CT) angiography (CTA) “spot sign” is a validated predictor of HE, it is not universally available, highlighting the need for accessible imaging tools. In this invited editorial, we discuss the study by Parry et al, who developed a simplified five-point prediction score based solely on non-contrast CT findings - baseline hematoma volume ≥ 30 mL, intraventricular hemorrhage, and the island, black hole, and swirl signs. Tested prospectively in 192 patients scanned within 4 hours of onset, the score showed a stepwise rise in HE risk from 7% at a score of 0% to 100% at a score of 5. We place these findings in the context of existing CTA and non-contrast CT literature and highlight their potential to accelerate triage and treatment, particularly where CTA is unavailable. Broader multicenter validation and integration with clinical and machine-learning approaches will further define the clinical impact of this streamlined, imaging-only tool.
Core Tip: Early prediction of hematoma expansion is critical to improving outcomes in spontaneous intracerebral hemorrhage. While the computed tomography (CT) angiography “spot sign” is a strong predictor of hematoma expansion, its routine use is limited. Non-contrast CT markers such as the swirl, black hole, and island signs offer a practical alternative. Parry et al introduce a simple, five-point non-contrast CT grading system that integrates these imaging signs with hematoma volume and intraventricular hemorrhage. This easy-to-apply score can guide rapid risk stratification, inform blood-pressure management and anticoagulation reversal, and help select candidates for anti-expansion therapies, even in resource-limited settings.
