Intracerebral Hemorrhage ICH Score

The scoring method explained

The intracerebral haemorrhage score stratifies 30- day mortality risk in patients with cerebral bleeding based on patient age, the result from the GCS assessment and hematoma volume, location and origin.

The scoring method should be administered at admission and 24h into hospitalization to help chart prognosis.

The five risk factors are:

■ The Glasgow Coma Scale evaluates level of consciousness, eye opening, verbal response and motor response. GCS is given the most weight in the scale and is divided in 3 subgroups:

3 – 4 (2 points);

5 – 12 (1 point);

13 – 15 (0 points).

■ Patient age is considered a relevant bleeding risk factor.

■ The existence of an intracerebral haemorrhage volume of 30 mL or more is checked as the amount of blood loss is linked to survival rate.

■ CT finding of intraventricular haemorrhage means that the risk of complications due to the cerebral hematoma is increased.

■ Hemorrhage with infratentorial origin, as opposed to supratentorial origin, poses a higher mortality risk.

Patients with low GCS and/ or signs of hydrocephalus on CT may need urgent ventricular decompression with an extra-ventricular drain (EVD).

Clinicians are also advised to take into account any anticoagulation or anti-platelet therapy, the patient may be under.

Transfer to ICU and permanent monitoring are required for patients suspected with intracranial haemorrhage, to prevent complications such as neurological decompensation or airways sequelae.

The ICH score can also be used to stratify 30-day mortality risk and 1 year functional outcome in spontaneous intracerebral hemorrhage (SICH).

Result interpretation

Each of the 5 risk factors is weighted differently, depending on the strength of independent association of the specified item.

The sum of points is then associated with a 30-day mortality risk in percentage:

About the study

The ICH score, aimed at becoming a standard clinical grading scale for ICH, was created in 2001 by Hemphill et al. following a study that reviewed patient data of admissions with acute ICH (during 1997-1998).

The five independent predictors of 30-day mortality were identified by logistic regression and different weights were awarded on the basis of their strength and association with mortality risk. It was found that mortality increased steadily with ICH score.

This clinical stratification system can improve standardization of clinical treatment protocols and clinical research studies in ICH.

Intracranial haemorrhage guidelines

ICH is a medical emergency that occurs when a blood vessel ruptures as a result of trauma, stroke or an aneurysm and defines all types of intracranial bleed, including:

■ Intraventricular;

■ Intraparenchymal;

■ Subarachnoid;

■ Epidural;

■ Subdural.

Build up of blood within the skull leads to an increase in intracranial pressure that limits normal blood supply to the brain, which in turn affects nervous function.

There are two types of ICH, intra-axial and extra-axial. The first one is the cerebral hemorrhage, meaning that bleeding occurs within the brain itself. The second type is bleeding that occurs outside of the brain tissue (i.e. subarachnoid haemorrhage).

Main causes of ICH include:

■ Head trauma;

■ Hypertensive leak;

■ Blood clotting in brain;

■ Ruptured cerebral aneurysm;

■ Cerebral amyloid angiopathy;

■ Anticoagulant therapy.

Presentation with ICH is characterised by weakness, numbness or paralysis of the face and/or limbs (usually unilateral), severe headache, difficulty swallowing and speaking, impaired vision and loss of balance or coordination. In severe cases, changes in level of consciousness and coma may occur.

Diagnosis involve physical examination, CT scan and MRI tests. Other non-specific tests include EKG, complete blood count or examination of the cerebrospinal fluid. 

Original source

Hemphill JC 3rd, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001; 32(4):891-7.

Validation

Clarke JL, Johnston SC, Farrant M, Bernstein R, Tong D, Hemphill JC 3rd. External validation of the ICH score. Neurocrit Care. 2004; 1(1):53-60.

Other references

1. Appelboom G, Hwang BY, Bruce SS, Piazza MA, Kellner CP, Meyers PM, Connolly ES. Predicting outcome after arteriovenous malformation-associated intracerebral hemorrhage with the original ICH score. World Neurosurg. 2012; 78(6):646-50.

2. Ruiz-Sandoval JL, Chiquete E, Romero-Vargas S, Padilla-Martínez JJ, González-Cornejo S. Grading scale for prediction of outcome in primary intracerebral hemorrhages. Stroke 2007; 38(5):1641-4.