Significant hematoma expansion (HE) affects one‐fifth of people within 24 hours after acute intracerebral hemorrhage (ICH), and its prevention is an appealing treatment target. Although the computed tomography (CT)‐angiography spot sign predicts HE, only a minority of ICH patients receive contrast injection. Conversely, noncontrast CT (NCCT) is used to diagnose nearly all ICH, so NCCT markers represent a widely available alternative for prediction of HE. However, different NCCT signs describe similar features, with lack of consensus on the optimal image acquisition protocol, assessment, terminology, and diagnostic criteria. In this review, we propose practical guidelines for detecting, interpreting, and reporting NCCT predictors of HE. ANN NEUROL 2019;86:480–492

Background and Purpose-Intracerebral hemorrhage (ICH) growth predicts mortality and functional outcome. We hypothesized that irregular hematoma shape and density heterogeneity, reflecting active, multifocal bleeding or a variable bleeding time course, would predict ICH growth. Methods-Three raters examined baseline sub-3-hour CT brain scans of 90 patients in the placebo arm of a Phase IIb trial of recombinant activated Factor VII in ICH. Each rater, blinded to growth data, independently applied novel 5-point categorical scales of density and shape to randomly presented baseline CT images of ICH. Density and shape were defined as either homogeneous/regular (Category 1 to 2) or heterogeneous/irregular (Category 3 to 5). Within-and between-rater reliability was determined for these scales. Growth was assessed as a continuous variable and using 3 binary definitions: (1) any ICH growth; (2) Ն33% or Ն12.5 mL ICH growth; and (3) radial growth Ͼ1 mm between baseline and 24-hour CT scan. Patients were divided into tertiles of baseline ICH volume: "small" (0 to 10 mL), "medium" (10 to 25 mL), and "large" (25 to 106 mL). Results-Inter-and intrarater agreements for the novel scales exceeded 85% (Ϯ1 category). Median growth was significantly higher in the large-volume group compared with the small group (PϽ0.001) and in heterogeneous compared with homogeneous ICH (Pϭ0.008). Median growth trended higher in irregular ICHs compared with regular ICHs (Pϭ0.084). Small ICHs were more regularly shaped (43%) than medium (17%) and large (3%) ICHs (PϽ0.001). Small ICHs were more homogeneous (73%) compared with medium (37%) and large (17%) ICHs (PϽ0.001). Adjusting for baseline ICH volume and time to scan, density heterogeneity, but not shape irregularity, independently predicted ICH growth (Pϭ0.046) on a continuous growth scale. Conclusions-LargeICHs were significantly more irregular in shape, heterogeneous in density, and had greater growth.Density heterogeneity independently predicted ICH growth using some definitions. Key Words: density Ⅲ growth Ⅲ intracerebral hemorrhage Ⅲ recombinant activated factor VII Ⅲ predictors Ⅲ shape I ntracerebral hemorrhage (ICH) is the most sinister stroke subtype with a high early mortality. 1,2 Despite this, there is convincing evidence that aggressive care can bring about meaningful recovery, even in the worst initial prognostic groups. 3,4 CT scanning remains the standard diagnostic technique for ICH. Hematoma growth occurs in Ͼ70% of patients on CT performed within 3 hours of symptom onset and independently predicts mortality and functional outcome. 5 Hemostatic therapy has been demonstrated to attenuate ICH growth in 2 pivotal studies of recombinant activated Factor VII administered within 4 hours of symptom onset. 6,7 In contrast, the clinical outcomes in these trials were discordant and the positive results were not replicated in the second, larger trial. 6,7 Attenuated hematoma growth has also been suggested in an acute blood pressure reduction trial. 8 Hence, hematoma growth is a key therapeu...