Prognostic Value of Four CT-Based Hemorrhage Markers: A Single-Center ICH Study (2017–2023)

Background and Purpose: Spontaneous intracerebral hemorrhage (ICH) is a severe stroke subtype characterized by high morbidity and mortality. Early hematoma expansion (HE) predicts poor outcomes, yet non-contrast CT (NCCT) markers that can be readily assessed in clinical practice remain underutilized. We evaluated four NCCT signs - Blend Sign (BS), Black Hole Sign (BHS), Irregular Shape (IRS), and Satellite Sign (SS) - and introduced a composite score (SUM_BBIS) to determine their association with key clinical and radiological outcomes. Methods: Between January 2017 and December 2023, we retrospectively examined 602 consecutive patients with spontaneous ICH at a single tertiary center; 404 met inclusion criteria, each un-dergoing baseline and follow-up NCCT. We identified BS, BHS, IRS, and SS on the initial scan and computed SUM_BBIS (range 0–4). Hematoma progression was defined as a volume increase >33% or >6 mL. Primary outcomes included the frequency of NCCT signs, hematoma expansion, and in-hospital mortality. Secondary analyses explored sign prevalence by hemorrhage volume, lo-cation, intraventricular extension, and comorbidities. Results: Of the 404 patients analyzed (mean SUM_BBIS=1.25), IRS was most frequent (59.4%), fol-lowed by SS (34.4%), BHS (30.9%), and BS (15.1%). Higher SUM_BBIS correlated with larger he-matomas, deep or brainstem locations, and comorbidities such as warfarin use, chronic kidney disease, or thrombocytopenia. Hematoma expansion occurred more often in those with at least one sign; BHS had the strongest association (56.2% in expanding vs. 23.8% in non-expanding hemor-rhages, p< 0.001). In-hospital mortality was significantly higher among patients with a greater number of signs: decedents had a mean SUM_BBIS of 1.95 compared to 0.93 for survivors (p< 0.001). Each sign was markedly more prevalent in non-survivors, with BHS again showing the largest difference (66.4% vs. 15.4%). Surgical intervention was more closely related to clinical and vol-umetric factors rather than the presence of NCCT markers. Conclusions: Four NCCT signs - Blend Sign, Black Hole Sign, Irregular Shape, and Satellite Sign—were significantly linked to increased hematoma expansion and in-hospital mortality. The Black Hole Sign proved to be the most potent single predictor of expansion, while multiple co-existing signs further elevated the risk of poor outcome. Incorporating these NCCT markers into routine acute ICH assessments may allow earlier identification of high-risk patients and more timely therapeutic intervention.