Determinants of Ultra-Early Aspiration Pneumonia in Acute Intracerebral Hemorrhage Presenting to the Emergency Department

<b>Background/Objectives</b>: Aspiration pneumonia is among the most frequent medical complications after intracerebral hemorrhage (ICH), yet its role during the ultra-early emergency department (ED) phase remains poorly understood. This study aimed to identify clinical and neurological factors independently associated with radiologically confirmed aspiration pneumonia in patients presenting with acute spontaneous ICH and to evaluate its association with early clinical outcomes. <b>Methods</b>: A retrospective observational cohort study was conducted in the neuro-emergency department of a large tertiary university hospital. All consecutive adults with spontaneous ICH confirmed by neuroimaging between January 2020 and December 2023 were included. Univariable and multivariable logistic regression models were used to identify independent predictors of pneumonia. <b>Results</b>: A total of 184 patients were analyzed (median age 74 years; 46% female). Radiologically confirmed aspiration pneumonia occurred in 37 patients (22.0%). Pneumonia was significantly associated with lower GCS, higher National Institutes of Health Stroke Scale (NIHSS) and ICH scores, shorter ED stay, and more frequent endotracheal intubation (ETI). In multivariable analysis, ETI (OR 5.42, 95% CI 1.57-18.63, <i>p</i> = 0.007), higher NIHSS score (OR 1.09, 95% CI 1.01-1.20, <i>p</i> = 0.047), and shorter ED stay (OR 0.97, 95% CI 0.95-0.99, <i>p</i> = 0.035) were independently associated with pneumonia. Aspiration pneumonia was not independently associated with neurosurgical referral (<i>p</i> = 0.082) or low GCS at discharge (<i>p</i> = 0.650). <b>Conclusions</b>: In this neuro-emergency cohort, aspiration pneumonia was common and strongly associated with neurological severity, particularly with endotracheal intubation and higher NIHSS scores. Although it did not independently predict early neurological deterioration or neurosurgical transfer, it identifies a critical period in which preventive measures-such as dysphagia screening, oral hygiene, and careful airway management-should be systematically applied. Larger multicenter studies with longer follow-up are needed to better define its long-term clinical consequences after ICH.