Non-Contrast CT Hemorrhage Markers and Outcomes in Intracerebral Hemorrhage: A Large Single-Center Cohort from Romania

Background and Purpose: Spontaneous intracerebral hemorrhage (ICH) is associated with high rates of morbidity and mortality. Early hematoma expansion (HE) is a key driver of poor outcomes, yet readily available non-contrast CT (NCCT) markers remain underused. We assessed four predefined NCCT signs—Blend Sign (BS), Black Hole Sign (BHS), Irregular Shape (IRS), and Satellite Sign (SS)—and a simple composite score (SUM_BBIS, 0–4) for their association with HE and in-hospital mortality. Methods: We retrospectively analyzed 404 consecutive adults with primary spontaneous ICH admitted to a tertiary-care center between January 2017 and December 2023. Patients with secondary causes of hemorrhage or without follow-up NCCT were excluded. Each sign was scored dichotomously by blinded readers and summed to form the SUM_BBIS. HE was defined as a >6 mL or >33% volume increase on repeat NCCT within 24–48 h. Outcomes included HE and in-hospital mortality; secondary analyses explored relationships with baseline hematoma volume, location, intraventricular extension (IVH), and comorbidities. Results: Among 404 patients, Irregular Shape was most frequent (62.1%), followed by Satellite Sign (34.9%), Black Hole Sign (31.1%), and Blend Sign (15.3%). Hematoma expansion occurred in 22.0% (89/404). Expansion was more common when ≥1 sign was present, with the Black Hole Sign showing the strongest association (56.2% vs. 23.8%; p < 0.001). In-hospital mortality rose stepwise with higher SUM_BBIS (mean 1.95 in non-survivors vs. 0.93 in survivors; p < 0.001). Conclusions: The four predefined NCCT signs, particularly BHS, identify ICH patients at increased risk of HE and in-hospital death. A simple, purely imaging-based composite (SUM_BBIS) captures cumulative radiological complexity and stratifies risk in a stepwise manner. Systematic evaluation of these markers may enhance early triage and inform timely therapeutic decisions, especially in emergency and resource-limited settings.