Vomiting, systolic BP (SBP) >220 mmHg, severe headache, coma or decreased level of consciousness, and symptom pro- gression over minutes or hours all suggest ICH, although none of these findings are specific; neuroimaging is thus mandatory.40 CT and magnetic resonance imaging (MRI) are both reasonable for initial evaluation. CT is very sensitive for identifying acute hemorrhage and is considered the gold standard ; gradient echo and T2* susceptibility-weighted MRI are as sensitive as CT for detection of acute hemorrhage and are more sensitive for identification of prior hemorrhage.41,42 Time, cost, proximity to the ED, patient tolerance, clinical status, and MRI availability may, however, preclude emergent MRI in many cases.43 The high rate of early neurological deterioration after ICH is related in part to active bleeding that may proceed for hours after symptom onset. Hematoma expansion tends to occur early after ICH and increases risk of poor functional outcome Among patients undergoing head CT within 3 hours of ICH onset, 28% to 38% have hematoma expan- sion of greater than one third of the initial hematoma volume on follow-up CT.7,45 As such, the identification of patients at risk for hematoma expansion is an active area of research. CT angiography (CTA) and contrast-enhanced CT may identify patients at high risk of ICH expansion based on the presence of contrast within the hematoma, often termed a spot sign.50 54 A larger number of contrast spots suggests even higher risk of Early diagnosis of underlying vascular abnormalities can both influence clinical management and guide prognosis in ICH patients. Risk factors for underlying vascular abnormalities are Table 4. 