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Objective To assess the efficacy of propensity matching score (PMS) to determine the value of island sign and mixed sign on unenhanced CT for predicting hematoma enlargement (HE) in spontaneous intracerebral hemorrhage (SICH). Methods From June 2017 to June 2021, 229 patients with SICH underwent cranial CT on admission to our hospital including 73 with and 156 without HE on follow-up CT within 24 hours. 43 cases in each of the HE and non-HE groups were included after 1:1 propensity matching score (PMS) matching. The clinical data before and after PMS were compared and the receiver operating characteristic (ROC) curve was used to analyze the predictive value of HE of island sign and mixed sign. Results Before PSM, there were significant differences in the incidence of hypertension and diabetes, admission Glasgow Coma Score (GCS), admission National Institute of Health Stroke Scale (NIHSS) score, admission systolic blood pressure, combined ventricular penetration, initial hematoma volume, island sign, and mixed sign between the two groups of SICH patients (P<0.05). Logistic regression analysis showed that hypertension, admission GCS score, admission low NIHSS score, initial hematoma volume, island sign, and mixed sign were independent influencing factors of HE (P<0.05). Between the 43 pairs of PMS-matched patients, there was significant difference in the incidence of island sign and mixed sign (P<0.05). The areas under the ROC curves, sensitivities, and specificities of predicting HE were 0.663, 83.7%, 48.8% for the island sign; 0.651, 74.4%, 55.8% for the mixed sign; 0.814, 90.7%, 72.1% for both signs. Conclusion The island sign and mixed sign on unenhanced CT have predictive value for HE in SICH and timely intervention measures should be taken to improve the prognosis [ABSTRACT FROM AUTHOR]