Käytännöllinen

ICH Score

ICH Score — Intracerebral Haemorrhage

Glasgow Coma Scale (GCS)

ICH-tilavuus (ABC/2-menetelmä)

Intraventricular Haemorrhage (IVH)

Infratentorial Origin

Ikä ≥ 80 vuotta

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Mikä on ICH Score?

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The ICH Score is a clinical grading system designed to predict 30-day mortality in patients with spontaneous intracerebral haemorrhage (ICH). It was developed by Hemphill and colleagues at the University of California San Francisco and published in 2001. The score incorporates five independently validated prognostic factors: Glasgow Coma Scale (GCS) score at presentation, ICH volume on CT scan, presence of intraventricular haemorrhage (IVH), infratentorial origin of the haemorrhage (posterior fossa), and patient age 80 years or older. Each component is dichotomised or categorised and assigned a weight of 0 or 1, except GCS which contributes 0, 1, or 2 points, yielding a total score from 0 to 6. The 30-day mortality associated with each score was derived from a validation cohort: 0 points carries 0% mortality, 1 point 13%, 2 points 26%, 3 points 72%, 4 points 97%, and scores of 5-6 are associated with approximately 100% 30-day mortality. The ICH Score is widely used in neurocritical care settings to communicate prognosis, guide family discussions about goals of care, and to stratify patients in clinical trials. Importantly, it predicts mortality and does not directly predict functional outcome. Clinicians should be aware that early mortality in ICH can be a self-fulfilling prophecy driven by withdrawal of care decisions, and the score should be used as a prognostic aid rather than a definitive guide to treatment limitation.

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f(x)

ICH Score = GCS[3-4=2pts, 5-12=1pt, 13-15=0pts] + ICH Volume[≥30mL=1pt, <30mL=0pts] + IVH Present[yes=1pt, no=0pts] + Infratentorial Origin[yes=1pt, no=0pts] + Age≥80[yes=1pt, no=0pts]; Total 0-6; 30-day mortality: 0=0%, 1=13%, 2=26%, 3=72%, 4=97%, 5-6≈100%

Muuttujan selitys

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Symboli	Nimi	Yksikkö	Kuvaus
V	ICH Volume	mL	The volume or capacity in cubic or liquid units, representing the three-dimensional space or fluid quantity
IF	Infratentorial Origin	yes/no	The annual interest rate or rate of return expressed as a decimal or percentage, representing the cost of borrowing or yield on investment over one year

Kuinka ICH Score

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1Assess the GCS score at presentation: GCS 3-4 scores 2 points (severe depression); GCS 5-12 scores 1 point (moderate depression); GCS 13-15 scores 0 points (mild or no depression).
2Measure ICH volume on non-contrast CT using the ABC/2 method: A (maximum haemorrhage diameter) × B (diameter perpendicular to A) × C (number of CT slices with haemorrhage × slice thickness) ÷ 2; ≥30 mL scores 1 point, <30 mL scores 0.
3Determine whether intraventricular haemorrhage is present on CT — blood visible in the ventricles scores 1 point.
4Identify the anatomical origin of the haemorrhage: infratentorial (cerebellum, brainstem, posterior fossa) scores 1 point; supratentorial location scores 0.
5Assess the patient's age: 80 years or older scores 1 point; under 80 scores 0.
6Sum all five components to calculate the ICH Score (0-6) and apply the 30-day mortality prediction.
7Use the score to guide conversations with patients and families about prognosis and goals of care, while acknowledging that early DNR orders can independently increase mortality.

Ratkaistut esimerkit

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Esimerkki 1Low-Risk ICH

Annettu:65-year-old, GCS 14, small right putaminal haematoma 15 mL, no IVH

Tulos:ICH Score = 0 — Predicted 30-day mortality 0%

Favourable prognosis; aggressive medical management appropriate

Young patient with small supratentorial bleed, near-normal consciousness, no IVH. Full medical management including blood pressure control and reversal of anticoagulation is indicated.

Esimerkki 2Moderate ICH Score

Annettu:74-year-old, GCS 9, right thalamic haemorrhage 32 mL with IVH

Tulos:ICH Score = 3 — Predicted 30-day mortality 72%

High mortality predicted; goals-of-care discussion with family essential

Multiple adverse prognostic factors combine to produce a high-risk score. EVD for hydrocephalus and aggressive ICP management may be warranted while family goals-of-care discussions are conducted.

Esimerkki 3Very High-Risk ICH

Annettu:83-year-old, GCS 4, massive cerebellar haemorrhage 45 mL with IVH

Tulos:ICH Score = 6 — Predicted 30-day mortality ~100%

Comfort-focused care should be discussed; futility of aggressive intervention is high

Maximum ICH Score in a very elderly patient with devastating haemorrhage. Surgical decompression could be considered for cerebellar bleed if clinically indicated, but overall prognosis is extremely poor.

Esimerkki 4Cerebellar Haemorrhage

Annettu:70-year-old, GCS 12, cerebellar haematoma 8 mL, no IVH

Tulos:ICH Score = 2 — Predicted 30-day mortality 26%

Consider neurosurgical evaluation — cerebellar haemorrhage >3 cm may benefit from evacuation

Despite small volume, infratentorial origin adds risk. Cerebellar haematomas >3 cm may cause rapid deterioration from brainstem compression and hydrocephalus, warranting lower surgical threshold than supratentorial bleeds.

Käytännön sovellukset

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Professionals in health and medical use Intracerebral Haemorrhage Score as part of their standard analytical workflow to verify calculations, reduce arithmetic errors, and produce consistent results that can be documented, audited, and shared with colleagues, clients, or regulatory bodies for compliance purposes.

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University professors and instructors incorporate Intracerebral Haemorrhage Score into course materials, homework assignments, and exam preparation resources, allowing students to check manual calculations, build intuition about input-output relationships, and focus on conceptual understanding rather than arithmetic.

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Consultants and advisors use Intracerebral Haemorrhage Score to quickly model different scenarios during client meetings, enabling real-time exploration of what-if questions that would otherwise require returning to the office for detailed spreadsheet-based analysis and reporting.

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Individual users rely on Intracerebral Haemorrhage Score for personal planning decisions — comparing options, verifying quotes received from service providers, checking third-party calculations, and building confidence that the numbers behind an important decision have been computed correctly and consistently.

Erikoistapaukset

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Extreme input values

In practice, this edge case requires careful consideration because standard assumptions may not hold. When encountering this scenario in intracerebral haemorrhage score calculations, practitioners should verify boundary conditions, check for division-by-zero risks, and consider whether the model's assumptions remain valid under these extreme conditions.

Assumption violations

Rounding and precision effects

ICH Score and 30-Day Mortality

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ICH Score	30-Day Mortality	Clinical Context
0	0%	Excellent prognosis; full active management
1	13%	Favourable; intensive management appropriate
2	26%	Guarded; goals-of-care discussion advisable
3	72%	Poor prognosis; early family conference essential
4	97%	Very high mortality; comfort measures discussion
5-6	~100%	Near-certain death; palliative approach appropriate

Usein kysytyt kysymykset

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Can ICH Score be used to withhold treatment?

No. The ICH Score should not be used in isolation to withhold aggressive treatment or write DNR orders. There is evidence that early withdrawal of care contributes to high early mortality in ICH, creating a self-fulfilling prophecy. The score is a prognostic aid for counselling, not a treatment decision protocol.

How is ICH volume calculated?

ICH volume is most commonly estimated using the ABC/2 formula: A is the longest diameter of the haematoma in centimetres, B is the diameter perpendicular to A, and C is the number of CT slices containing haematoma multiplied by the slice thickness in centimetres. Divide the product by 2 to get the approximate ellipsoid volume.

What is the significance of intraventricular haemorrhage in ICH?

Intracerebral Haemorrhage Score is a specialized calculation tool designed to help users compute and analyze key metrics in the health and medical domain. It takes specific numeric inputs — typically drawn from real-world data such as measurements, rates, or quantities — and applies a validated mathematical formula to produce actionable results. The tool is valuable because it eliminates manual calculation errors, provides instant feedback when exploring different scenarios, and serves as both a decision-support instrument for professionals and a learning aid for students studying the underlying principles.

What are the components of the ICH Score and how are they weighted?

The ICH Score consists of five components: Glasgow Coma Scale (GCS) score, ICH volume, intraventricular hemorrhage, infratentorial origin of the hemorrhage, and the patient's age. Each component is assigned a points value, with a total score ranging from 0 to 6. For example, a GCS score of 3-4 is assigned 2 points, while a GCS score of 5-12 is assigned 1 point, and a GCS score of 13-15 is assigned 0 points. The total score is then used to predict 30-day mortality, with higher scores indicating a poorer prognosis.

How does the ICH Score perform in predicting 30-day mortality in patients with intracerebral hemorrhage?

Studies have shown that the ICH Score is a reliable predictor of 30-day mortality in patients with intracerebral hemorrhage, with a reported area under the receiver operating characteristic curve (AUC) of 0.78. The score has been validated in various patient populations, including those with supratentorial and infratentorial hemorrhages. For example, a score of 0 is associated with a 30-day mortality rate of 0%, while a score of 6 is associated with a 30-day mortality rate of 100%. The ICH Score has been widely adopted as a clinical grading system to guide treatment decisions and prognostication in patients with ICH.

Yleisiä virheitä vältettäväksi

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!Using the ICH Score to justify early withdrawal of care without family consultation or specialist input — this is associated with self-fulfilling mortality.
!Measuring ICH volume incorrectly using the ABC/2 method — common errors include using radius rather than diameter, or applying it to irregularly shaped haematomas where it is inaccurate.
!Forgetting that the GCS must be assessed before sedation or intubation for the admission score to be valid.
!Not reassessing prognosis after haematoma stability is confirmed at 24-48 hours — initial high scores can improve if haematoma does not expand and ICP is controlled.
!Applying ICH Score to traumatic intracerebral haematomas, where the tool has not been validated.

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Ammattilaisen vinkki

Always use the ABC/2 method consistently for ICH volume estimation and document the CT slice thickness used. A 5 mm slice thickness gives less accurate volume estimates than 1-2 mm reconstruction slices. For irregular haematomas, consider volumetric software tools for greater accuracy.

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Tiesitkö?

When Hemphill et al. published the ICH Score in 2001, it was the first widely adopted clinical prediction rule for ICH mortality. Within a decade, multiple studies demonstrated that early care withdrawal at high ICH Scores could self-fulfil the predicted mortality — prompting a major debate in neurocritical care about prognostic tools and their ethical implications.

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