What is the intracerebral hemorrhage (ICH) score, how is it calculated, and how does it guide prognosis and management?

ICH Score: Definition, Calculation, and Clinical Application

What is the ICH Score?

The ICH Score is a validated 0-6 point clinical grading scale that predicts 30-day mortality in patients with intracerebral hemorrhage, serving as the standard tool for risk stratification at presentation. 1, 2

The score was developed to provide a simple, reliable method analogous to grading scales used for traumatic brain injury and subarachnoid hemorrhage. 2

How to Calculate the ICH Score

The ICH Score assigns points based on five independent predictors of mortality, with a maximum total of 6 points: 1, 2

Component Variables:

• Glasgow Coma Scale (GCS) score:

  • GCS 3-4 = 2 points
  • GCS 5-12 = 1 point
  • GCS 13-15 = 0 points 2

• Age:

  • ≥80 years = 1 point
  • <80 years = 0 points 2

• ICH Location:

  • Infratentorial origin = 1 point
  • Supratentorial = 0 points 2

• ICH Volume:

  • ≥30 cm³ = 1 point
  • <30 cm³ = 0 points 2

• Intraventricular Hemorrhage (IVH):

  • Present = 1 point
  • Absent = 0 points 2

Measuring ICH Volume:

Use the ABC/2 formula for rapid bedside calculation: A (largest diameter on CT) × B (diameter perpendicular to A) × C (number of CT slices with hemorrhage × slice thickness) ÷ 2. 3 This method takes approximately 38 seconds, correlates excellently with planimetric measurements (R² = 0.96), and has outstanding inter-rater reliability (intraclass correlation = 0.99). 3

Prognostic Value and Mortality Prediction

The original ICH Score validation demonstrated a clear mortality gradient: 2

• ICH Score 0: 0% mortality (all 26 patients survived)
• ICH Score 1: 13% mortality
• ICH Score 2: 26% mortality
• ICH Score 3: 72% mortality
• ICH Score 4: 97% mortality
• ICH Score 5: 100% mortality (all 6 patients died) 2

The score demonstrates high specificity (95% at baseline) but lower sensitivity (36% at baseline), with positive predictive values ranging from 57-76%. 4 A 72-hour ICH score improves sensitivity to 75% but reduces specificity to 89%. 4

The ICH Score correlates significantly with functional outcomes measured by modified Rankin Scale at discharge (R=0.667), 1 month (R=0.66), and 2 months (R=0.765). 5

How the ICH Score Guides Clinical Management

Appropriate Uses:

Administer the ICH Score as part of initial evaluation to provide an overall measure of clinical severity and create a general framework for communication with patients and caregivers. 1 The score is valuable for:

• Risk stratification in clinical protocols 2
• Standardization of research studies 2
• Quality care metrics 1
• Clinical trial patient selection 1

Critical Limitations and Pitfalls:

Never use the ICH Score as the sole basis for forecasting individual prognosis or limiting life-sustaining treatment. 1 This is a Class III (Harm) recommendation because:

• Recent data shows observed mortality in moderate-grade patients (ICH Score 3-4) is significantly lower than originally predicted (49% vs 72% for score 3; 71% vs 97% for score 4), suggesting the score may overestimate mortality with modern care. 6

• The score can become a self-fulfilling prophecy when used to justify early withdrawal of care—56.6% of deaths in one cohort involved withdrawal of care decisions that increased with higher ICH scores. 6

• For patients without preexisting documented requests for life-sustaining therapy limitations, aggressive care should continue with postponement of new DNAR orders or withdrawal of medical support until at least the second full day of hospitalization. 1 This approach decreases mortality and improves functional outcomes. 1

Alternative Prognostic Tools:

The Max-ICH score was specifically developed to minimize confounding by early care limitation and has been validated as superior to the ICH Score among patients who do not have early withdrawal of life-sustaining treatment. 1 Consider using this alternative when early care limitation is a concern. 1

Key Clinical Pearls:

• The ICH Score remains useful for standardization and communication but should not drive withdrawal-of-care decisions in the first 48 hours. 1, 6
• Modern mortality rates are lower than originally predicted, particularly for intermediate scores (3-4), regardless of surgical intervention. 6
• Document the ICH Score as standard procedure in acute care and follow-up of all ICH patients. 5
• Use shared decision-making models between surrogates and physicians for patients unable to participate in medical decision-making. 1