What scores are used to monitor intracerebral (ic) bleed?

Scoring Systems for Intracerebral Hemorrhage Monitoring

The National Institutes of Health Stroke Scale (NIHSS) and Glasgow Coma Scale (GCS) are the primary validated scores used for monitoring intracerebral hemorrhage, with the ICH Score being the most reliable prognostic tool for predicting mortality and outcomes. 1

Primary Assessment Scales

NIHSS (National Institutes of Health Stroke Scale)

• Provides quantification of neurologic deficits that allows easy communication of severity among healthcare providers 1
• Can be completed quickly at bedside and should be performed on admission with abbreviated versions for more frequent assessments 1
• Valuable prognostic information that correlates with infarct volume 1
• Patients with NIHSS score <10 have more favorable outcomes at 1 year compared to those with scores >20 1
• Helps identify patients at higher risk for ICH after thrombolytic treatment (NIHSS >22 associated with 17% risk of ICH) 1

Glasgow Coma Scale (GCS)

• Well-known, easily computed scale that serves as a strong predictor of long-term outcome 1
• Used in critical care monitoring protocols for suspected ICH 1
• Component of the ICH Score (see below) 2
• Should be checked every hour in patients with confirmed ICH 1

Prognostic Scoring Systems

ICH Score

• Most validated clinical grading scale specifically for intracerebral hemorrhage 2
• Comprises five independent predictors of 30-day mortality:
  1. GCS score (3-4 = 2 points, 5-12 = 1 point, 13-15 = 0 points)
  2. Age ≥80 years (Yes = 1 point, No = 0 points)
  3. Infratentorial origin (Yes = 1 point, No = 0 points)
  4. ICH volume ≥30 cm³ (Yes = 1 point, No = 0 points)
  5. Intraventricular hemorrhage (Yes = 1 point, No = 0 points) 2
• Total score ranges from 0-6 with higher scores associated with increased mortality 2
• Patients with ICH Score of 0 have excellent survival rates, while those with scores of 5 have extremely poor prognosis 2
• Can be used to determine appropriate level of care (patients with ICH score ≤2 may be safely managed in step-down units rather than neurocritical care units) 3

Volume Assessment

• Hemorrhage volume is the strongest independent predictor of 30-day mortality 4
• Can be calculated using the ABC/2 formula (ellipsoid method) 4
• Three volume categories with prognostic significance:
  • 0-29 cm³ (better prognosis)
  • 30-60 cm³ (intermediate prognosis)

  • 60 cm³ (poor prognosis) 4

• Volume combined with GCS predicts mortality with high sensitivity (96%) and specificity (98%) 4

Monitoring Parameters for ICH Management

Blood Pressure Monitoring

• For SBP >200 mmHg or MAP >150 mmHg: continuous IV infusion with monitoring every 5 minutes 1
• For SBP >180 mmHg or MAP >130 mmHg with possible elevated ICP: monitor ICP and maintain cerebral perfusion pressure ≥60 mmHg 1
• For SBP >180 mmHg or MAP >130 mmHg without elevated ICP: modest reduction with clinical reexamination every 15 minutes 1

Intracranial Pressure (ICP) Monitoring

• Consider for patients with GCS score ≤8, clinical evidence of transtentorial herniation, or significant IVH/hydrocephalus 1
• Target cerebral perfusion pressure (CPP) of 50-70 mmHg depending on autoregulation status 1
• Percentage of ICP readings above 30 mmHg is an independent predictor of mortality 1

Radiographic Monitoring

• CT scan is the preferred initial imaging modality 5
• Follow-up imaging at 24 hours to assess for hemorrhage expansion 1
• Hemorrhage expansion definitions:
  • Absolute increase of 6.0-12.5 mL
  • Relative increase of 20-33% 1

Clinical Monitoring Protocol

Acute Phase (First 24 Hours)

• Vital signs every 15 minutes for first 2 hours, then every 30 minutes for 6 hours, then hourly 1
• Neurological examination and signs of increased ICP every 15 minutes 1
• Continuous ECG monitoring 1
• Complete blood count, electrolytes, renal function, glucose, coagulation studies (PT/INR, aPTT) 1
• Toxicology screen in young or middle-aged patients 1

Post-Acute Phase (24-72 Hours)

• Vital signs hourly and as needed 1
• GCS/pupil check every hour 1
• Monitor for signs of hydrocephalus, which predicts poor outcome 1
• Consider ventricular drainage for hydrocephalus in patients with decreased level of consciousness 1

Pitfalls and Caveats

• Automatic blood pressure cuffs should be used with caution to prevent hematoma formation; check cuff site frequently and rotate every 2 hours 1
• Avoid invasive procedures in the first 24 hours after thrombolytic treatment 1
• Higher serum glucose and creatinine are associated with hematoma expansion and worse outcomes 1
• No clear treatment thresholds for ICP have been identified; monitoring should be guided by clinical status 1
• When using ICH scores for clinical decision-making, remember they are statistical tools and individual patient factors may influence outcomes 6, 7