Background: Hematoma expansion (HE) is the leading cause of early neurological deterioration, poor functional outcome, and increased mortality in patients with spontaneous intracerebral hemorrhage (S-ICH). The study aimed to estimate the risks and predictors of early HE in patients with S-ICH and the effect of this HE on patient's survival and functional outcome. Methods: This study was carried out on 72 patients with S-ICH submitted to baseline non-contrast brain CT (NCCT) and CT angiography for determination of hematoma site, size, border irregularity, blend sign, and spot sign score (SSS). Rescan was done 48 h after stroke onset or on clinical deterioration to resize the HV and diagnose HE. Modified Rankin Scale (MRS) was done 3 months after stroke onset to assess the effect of HE on patients' physical dependence. Results: HE occurred in 28/72 (38.9%) of included patients. Risks of HE included old age, smoking, elevated baseline mean arterial blood pressure, and high admission modified National Institute of Health stroke scale. NCCT predictors of HE included large volume, irregular border, and presence of blend sign. The presence of spot sign in early CTA is more accurate than NCCT predictors with 54%, 91%, 79%, and 75% for sensitivity, specificity, positive predictive value, and negative predictive value, respectively. Conclusions: HE is a major cause of early clinical deterioration, increased mortality, and poor functional outcome. Early CTA for detection of spot sign is indicated in patients with large volume, irregular border, and/or blend sign in NCCT.