Toward rapid, practical risk stratification in spontaneous intracerebral hemorrhage

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.

Key Words: Intracerebral hemorrhage; Non-contrast computed tomography; Stroke; Hematoma expansion

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.

TO THE EDITOR

Spontaneous intracerebral hemorrhage is among the most devastating forms of stroke, with mortality and long-term disability rates exceeding those of ischemic stroke[1]. Hematoma expansion (HE), occurring in roughly one-fifth of patients - most often within the first 24 hours - has emerged as a key, potentially modifiable determinant of poor outcome. The critical challenge for clinicians is to identify, at first imaging, those patients who will benefit from urgent interventions to limit hematoma growth[2-4].

FROM SPOT SIGN TO NCCT MARKERS: THE EVOLVING LANDSCAPE

Computed tomography (CT) angiography (CTA) “spot sign” remains the best-validated imaging predictor of HE. Yet CTA is not universally available and may delay treatment[5]. This has driven a shift toward non-contrast CT (NCCT), the frontline imaging test in acute stroke. Over the past decade, a series of NCCT markers - such as the swirl, black hole, blend, and island signs - have gained recognition as surrogates for active bleeding[6]. Parallel efforts have combined these and other clinical factors into multivariable scores (e.g., BAT score, GIVE score)[7]. While promising, many of these models require precise timing, complex measurements, or additional imaging, which can limit their use in routine emergency care.

THE CONTRIBUTION OF THE CURRENT STUDY

In this issue, Parry et al[8] present a pragmatic alternative: A five-point NCCT-based grading system incorporating baseline hematoma volume ≥ 30 mL, intraventricular hemorrhage, and three validated NCCT signs (island, black hole, and swirl). Each component is binary and quickly recognizable on standard NCCT. In a prospective cohort of 192 patients scanned within four hours of onset, risk of HE increased stepwise - from 7% at a score of 0% to 100% at a score of 5 - demonstrating both simplicity and strong predictive performance[8].

This approach has several strengths. It is immediately actionable, requiring no contrast injection or specialized software. It fits resource-limited settings where CTA is not routine. And it enables hyperacute decision-making, supporting early blood-pressure control, reversal of anticoagulation, or enrollment in trials of anti-expansion therapies such as tranexamic acid or recombinant activated factor VII.

CONCLUSION

As with any single-center study, external validation across diverse populations and imaging protocols is essential. Future work could integrate this grading system into multicenter trials or combine it with clinical variables and machine-learning methods to further refine risk stratification. Nevertheless, the study by Parry et al[8]. represents an important step toward streamlined, universally accessible prediction of HE, aligning with the urgent clinical imperative that “time is brain” in hemorrhagic as well as ischemic stroke.