Ultra-early follow-up computed tomography detects hematoma expansion in intracerebral hemorrhage with high accuracy

Background and objectives: This study investigates whether ultra-early follow-up imaging can reliably identify patients at risk for hematoma expansion (HE) in acute intracerebral hemorrhage (ICH). Methods: In this multicenter study, we analyzed data from patients with primary ICH who underwent at least two non-contrast cranial computed tomography (NCCT) scans within 7 days of symptom onset or last known well. To define the optimal time window, hematoma growth dynamics were retrospectively assessed in a large cohort (n = 1,663). Based on these findings, a prospective sub-study included patients with repeated imaging within 200 min (n = 46). HE was defined as >6 mL or >33% volume increase between the admission and the second follow-up scan. The diagnostic performance of early volume increase was evaluated using receiver operating characteristic (ROC) analysis. Results: The highest proportion of patients with active hemorrhage was detected within the first 200 min in the initial phase of this study. In the prospective sub-study, percentage volume increase between admission and early follow-up imaging demonstrated excellent diagnostic performance for HE (AUC = 0.819). At an optimized cutoff, the model yielded a sensitivity of 0.885 and a positive predictive value (PPV) of 74%. Among patients with early expansion already visible at follow-up, 50% showed further volume increase on the final scan. A separate analysis limited to follow-up imaging within the first 120 min after symptom onset (n = 27) revealed a higher diagnostic accuracy, with an AUC of 0.846 (sensitivity 0.857; PPV 71%). Conclusion: ICH evolves rapidly in the first hours after onset. Follow-up imaging within the first 200 min can diagnose hematoma growth with high sensitivity and good accuracy. However, the inability to distinguish between ongoing and completed expansion underscores the need for additional imaging or clinical markers to support clinical decisions.