Small Intracerebral Hemorrhage: Baseline CT Edema-to-Hematoma Ratio as an Independent Predictor of Early Expansion

Small intracerebral hemorrhage (ICH), defined as baseline NCCT hematoma volume (HV) <30 mL, is often considered lower risk for early expansion. We tested whether the edema-to-hematoma ratio (EHR) on baseline NCCT independently predicts expansion and whether combining EHR with HV enables practical bedside risk stratification.

We retrospectively analyzed 219 conservatively managed patients with small-volume ICH. Baseline NCCT underwent artificial intelligence-assisted 3D volumetry to quantify HV and perihematomal edema and to compute EHR. The primary outcome was binary early hematoma expansion on the first follow-up CT. Multivariable logistic regression included HV, EHR, age, deep location, intraventricular hemorrhage, and anticoagulation status. Discrimination and calibration were assessed with 5-fold cross-validation. Youden index cut-points were used to derive a simple bedside rule combining HV and EHR.

Early expansion occurred in 20.1% (44/219). Lower EHR and larger HV independently predicted expansion. Per 0.10 increase in EHR, adjusted odds decreased by 23% (adjusted OR [aOR], 0.77; 95% CI, 0.66-0.88); per additional 5 mL in HV, odds increased by 37% (aOR, 1.37; 95% CI, 1.09-1.73). A bedside rule (HV ≥9.2 mL plus EHR ≤0.683) identified a high-risk phenotype with a 39.3% expansion rate vs 4.4% in the low-risk reference. The multivariable model outperformed either predictor alone (area under the curve, 0.748 vs 0.700 and 0.672) with acceptable calibration (intercept, -0.17; slope, 0.92; Brier score, 0.141).

A lower baseline EHR independently predicts early expansion in small-volume ICH. Pairing EHR with HV yields a practical bedside rule with a large risk gradient and improves discrimination beyond volume alone, supporting targeted monitoring and timely repeat imaging.