Follow-up imaging after hospital discharge for acute intracerebral hemorrhage in European academic hospitals: a decision-making analysis

PURPOSE: To investigate factors guiding follow-up imaging after hospital discharge in atraumatic intracerebral hemorrhage (ICH) across large European academic centers and compare decision-making patterns using a standardized approach. METHODS: Expert neuroradiologists from nine European centers in eight countries detailed their follow-up algorithms for deep and lobar ICH, specifying (1) patient-related decision criteria, (2) preferred imaging modalities, and (3) advised follow-up timing. Free-text and schematic inputs were harmonized into uniform decision trees, mapping recommended modalities (CT, MRI/MRA, DSA, CTA) to patient-factor constellations. The primary endpoint was the distribution of recommended strategies; the secondary endpoint was inter-center consensus (≥ 50% agreement). RESULTS: Key decision criteria were hemorrhage location, suspected structural macrovascular pathology (SMVP), age, hypertension, and small-vessel disease. MRI/MRA was recommended by all centers and appeared in nearly all decision branches; “no further imaging” was rare. Additional strategies variably combined MRI/MRA with DSA and/or CTA, whereas stand-alone DSA as first follow-up test was uncommon. Formal consensus was achieved in a minority of clinical scenarios, most consistently for deep ICH, where MRI/MRA reached around 60% support. In young patients with lobar ICH and suspected SMVP, no single strategy reached consensus. The most frequently proposed timepoint for follow-up imaging was 6–12 weeks after discharge. CONCLUSION: In current European practice, MRI/MRA at 6–12 weeks represents the predominant follow-up strategy after ICH discharge, with CTA ± DSA added when SMVP is suspected. Despite this MRI-centered pattern, substantial inter-center heterogeneity persists, underscoring the need for standardized follow-up imaging with clearly defined timelines and protocols.