Insights into motor cortex remodeling may enable the development of more effective rehabilitation strategies during the acute phase. We aim to assess the affected and unaffected motor/premotor/somatosensory cortex resting state functional connectivity (RSFC) and reactivity with continuous wave functional near-infrared spectroscopy (cw-fNIRS) in patients with ICH compared to age, sex, and comorbidity-matched subjects. We enrolled patients with acute–subacute hemispheric ICH (
n = 37; two were excluded due to artifacts) and grouped them according to the side (right and left) of the stroke. Matched participants or patients with recent transient ischemic attack were enrolled as control subjects for the study (
n = 44; five were excluded due to artifacts). RSFC was assessed in both affected and unaffected hemispheres by group-level seed-based (primary motor cortex, priMC) correlation analysis. FT-associated relative oxyhemoglobin (ΔHbO) changes were analyzed in affected and unaffected hemispheres with generalized linear model regression. In left hemispheric ICH, the resting state coherence between the affected priMC and the affected premotor cortex (preMC) increased (
β = 0.83, 95% CI = 0.19, 1.47,
p = 0.01). In contrast, in right hemispheric ICH, the coherence between the unaffected priMC and the affected preMC decreased (
β = −0.6, 95% CI = −1.12, −0.09,
p = 0.02). In the left hemispheric ICH, the left-hand FT was associated with increased ΔHbO over the affected preMC (
β = 0.01, 95% CI = 0.003, 0.02,
p = 0.01). In contrast, in right hemispheric ICH, the left-hand FT was associated with increased ΔHbO over the unaffected preMC (
β = 0.02, 95% CI = 0.006, 0.04,
p = 0.01). Left hemispheric preMC may be involved in motor cortex reorganization in acute ICH in either hemisphere. Further studies may be required to assess longitudinal changes in motor cortex reorganization to inform acute motor rehabilitation.
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