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Introduction: Spontaneous intracerebral hemorrhage (ICH) accounts for 40% of stroke in children. Few studies report cognitive outcomes and none have conducted serial testing over time. We hypothesized that children with ICH would continue to make cognitive improvements over a two-year period.Methods: Children with spontaneous ICH, including those with primary intraparenchymal hemorrhage (IPH) and/or intraventricular hemorrhage (IVH), were prospectively enrolled from 2011-2015 at a single institution. Two raters measured total brain volume, IPH, and IVH volumes. Outcome was assessed with the Pediatric Stroke Outcome Measure and a cognitive testing battery (Wechsler IQ) at 3 (T1), 12 (T2) and 24 months (T3) after ICH.Results: Sample included 7 children, 6-16 years (median=12.9); 2 had pure ICH, 1 had pure IVH, and 4 had both. Brain AVM was the cause of ICH in 6 of 7; 1 was idiopathic. Initial Glasgow coma scale ranged from 3-14 (median=9). Median hemorrhage volume as a percentage of brain volume was 1.96, interquartile range (IQR) 1.17-3.74. Total PSOMs improved over time from median of 3 (IQR=1.5-4.5) at T1 to 2 (IQR =0.5-3.0) at T3. PSOM worsened in 2 children, 1 with recurrent ICH (pt #2) and 1 with worsening expressive language and increased depression despite full surgical resection of AVM (pt #3). However, serial cognitive testing indicated greater heterogeneity over time, including general improvements in Verbal IQ and sustained low performance in working memory and processing speed in a subgroup (Figure).Conclusion: Children with spontaneous ICH may continue to improve cognitively over two years. However, cognitive performance is heterogeneous across participants and across domains of cognitive functioning with some worsening as cognitive demands increase developmentally with age. Clinical implications include the need for early and serial cognitive testing to assess for cognitive difficulties as children age.