Editorial: Frontiers in the Neuro-Imaging of Acute Spontaneous Intracerebral Hemorrhage

Marc A. Babi ^* Whitney Mayberry Ahmed Koriesh Amre Nouh

• Cleveland Clinic Florida, Weston, United States

Intracerebral hemorrhage (ICH) is the most devastating subtype of stroke, estimated to account for 10-20% of the nearly 795,000 strokes occurring annually in the United States alone (1,8,9). The unique pathophysiology of ICH-demands rapid diagnosis and risk stratification to optimize patient outcomes given its high mortality rate of 30-40% within the first month (7,8).. Over the last decade, imaging has become central in the triaging, diagnosis, prognostication, acute management and prevention of ICH (5,7,9). Computed tomography (CT) remains the first-line modality for detecting ICH owing to its widespread availability and high sensitivity (2). However, advanced CT techniques within CT-such as angiography, perfusion, and radiomics-combined with magnetic resonance imaging (MRI) sequences (e.g., susceptibility-weighted imaging and diffusion-weighted imaging) have greatly enhanced the clinicians' ability to characterize higher-risk ICH, identify patients at higher risk of clinical decline and to tailor medical and surgical interventions accordingly (1,4,6). This editorial summarizes recent literature findings and highlights gaps and opportunities in acute ICH imaging.Non-contrast CT (NCCT): NCCT remains the clinical gold standard for the initial diagnosis of acute ICH. It distinguishes between hemorrhagic and ischemic stroke with high sensitivity in the hyperacute phase. Acute intracranial hemorrhage will present as hyperdense areas on NCCT (7,9). However, NCCT has key limitations, including lower sensitivity for subacute or chronic bleeds, and limited ability to determine underlying etiologies such as cerebral amyloid angiopathy (CAA) or vascular malformations (8).Computed Tomography Angiography (CTA): CTA is often performed alongside NCCT to identify underlying vascular pathologies such as aneurysms, arteriovenous malformations, or other intracranial arteriopathies (7,8). Additionally, CTA can also detect dynamic contrast extravasation ("spot sign")a helpful radiographic biomarker associated with increased risk of hematoma expansion (6,8). This information can critically influence acute management, guiding intensive blood pressure reduction or consideration for additional hemostatic therapies.Advanced CT-based Radiomics: Radiomics-an approach using advanced computational methods to extract quantitative features (shape, intensity, texture) from standard imaging-has recently emerged as a powerful tool for ICH research (5,6). By analyzing subtle differences not readily apparent to the clinician, radiomics can generate predictive models for hematoma expansion and outcome. These AI and machine learning-derived features, combined with clinical markers, hold promise for tailored treatment strategies. However, a major limitation is the lack of standardization and lack of external validation. MRI Sequences: Magnetic Resonance Imaging (MRI) offers superior tissue contrast and may detect small hemorrhages, chronic microbleeds, or underlying lesions such as cavernomas or other hemorrhagic brain lesions, more effectively than CT (1,(6)(7)(8). In addition, several MRI-based sequences may provide additional clinical insight that guides etiology, acute and chronic management of ICH. Some of these sequences include: ICH patients -linking imaging findings to systemic physiological parameters. In their retrospective analysis, the investigators observed that elevated serum osmolality (≥295 mmol/L) was associated with higher in-hospital mortality. These findings, although not tied directly to imaging, highlighted how systemic states (such as intravascular volume status, renal dysfunction, dehydration or hyperglycemia) might interplay with imaging markers of hemorrhage. The findings can further guide and screen for more prognostic markers and provide basis for disease monitoring, treatment decision-making, and prognosis improvement in ICH patients as well as guide future protocols that combine biochemical analyses with advanced imaging for further risk stratification in this patients' population. The updated American Heart Association/American Stroke Association guidelines tie together many of these emerging findings under a clinical practice umbrella. The guidelines reassert the importance of immediate neuroimaging to confirm hemorrhage, identify high risk patients based on radiographic markers and clinical signs, and delineate morphological features that predict expansion or poor outcome. They also spotlight evolving consensus on advanced imaging-whether CTA to detect vascular abnormalities or SWI to detect microbleeds-and emphasize that these techniques must be incorporated in a structured, time-sensitive manner. By highlighting knowledge gaps-such as how frequently repeat imaging should be performed, how best to integrate imaging-derived biomarkers into treatment decisions, use of emerging AI and automated tools, and how to standardize protocols, the guidelines effectively serve as a call to action, urging clinicians and researchers to refine the integration of advanced imaging within clinical workflows.In summary, this topic highlights the remarkable strides that have been made in the neuroimaging of