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The detection of contrast extravasation on computed tomography (CT) angiography, known as the spot sign, was initially embraced as a promising radiological marker for predicting HE that could aid patient selection for acute interventions aimed at minimizing HE. However, the initial enthusiasm waned as clinical studies failed to show clear clinical benefits of hemostatic treatments when patients were selected based on the presence of this imaging marker. In this narrative review, we provide a comprehensive summary of the pathophysiology, definitions, imaging protocols, and predictive performance of the spot sign, along with the clinical studies that have selected and treated patients based on its presence. Finally, we delve into some nuances of the spot sign that can enhance its predictive performance and help stratify HE risk with greater precision. These features include static findings observed on single-phase CT angiography (ie, number, volume, CT density, and colocalization with hypodensities), as well as dynamic findings identified on multiphase\/dynamic CT angiography (ie, timing of appearance, volume increase, volume decrease for tissue dispersion, and CT density changes). In this reappraisal of the spot sign, we aim to reinvigorate research on advanced neuroimaging in intracerebral hemorrhage that could lead to a more accurate HE prediction. This could facilitate better selection for therapies aimed at preventing HE or surgical approaches to address the bleeding source.<\/jats:p>","DOI":"10.1161\/strokeaha.125.050637","type":"journal-article","created":{"date-parts":[[2025,4,8]],"date-time":"2025-04-08T05:27:53Z","timestamp":1744090073000},"page":"1612-1624","update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":23,"title":["Spot Sign in Intracerebral Hemorrhage: Critical Reappraisal and Future Clinical Implications"],"prefix":"10.1161","volume":"56","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4042-4735","authenticated-orcid":true,"given":"Umberto","family":"Pensato","sequence":"first","affiliation":[{"name":"Department of Neurology, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan, Italy (U.P.)."},{"name":"Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Milan, Italy (U.P.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1379-3612","authenticated-orcid":true,"given":"Dar","family":"Dowlatshahi","sequence":"additional","affiliation":[{"name":"Division of Neurology, Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ontario, Canada (D.D., V.Y.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8053-4536","authenticated-orcid":true,"given":"David","family":"Rodriguez-Luna","sequence":"additional","affiliation":[{"name":"Stroke Unit, Department of Neurology, Hospital Universitari Vall d\u2019Hebron, Barcelona, Spain (D.R.-L.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0029-6764","authenticated-orcid":true,"given":"Johanna M.","family":"Ospel","sequence":"additional","affiliation":[{"name":"Department of Radiology, University of Calgary, Cumming School of Medicine, Alberta, Canada (J.M.O.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6558-1155","authenticated-orcid":true,"given":"Andrea","family":"Morotti","sequence":"additional","affiliation":[{"name":"Department of Clinical and Experimental Sciences, Neurology Unity, University of Brescia, Italy (A.M.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6501-4057","authenticated-orcid":true,"given":"Koji","family":"Tanaka","sequence":"additional","affiliation":[{"name":"Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (K.T., A.M.D.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8814-6853","authenticated-orcid":true,"given":"Vignan","family":"Yogendrakumar","sequence":"additional","affiliation":[{"name":"Division of Neurology, Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ontario, Canada (D.D., V.Y.)."},{"name":"Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital and University of Melbourne, Parkville, Victoria, Australia (V.Y., S.M.D., N.Y.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5749-3000","authenticated-orcid":true,"given":"Javier M.","family":"Romero","sequence":"additional","affiliation":[{"name":"Department of Neuroradiology (J.M.R.), Massachusetts General Hospital, Boston."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7044-8394","authenticated-orcid":true,"given":"H. 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