Toward rapid, practical risk stratification in spontaneous intracerebral hemorrhage

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 <i>et al</i>, 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.