Give me a detailed, uh, lecture on how to do the ICH scoring, like intracranial scoring.
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I have all the data I need. Here is the detailed lecture:
The ICH Score: A Detailed Lecture
Background and Purpose
The ICH score was developed and published by Hemphill and colleagues in 2001 (Stroke 32:891-897) as a simple, reliable grading scale for intracerebral hemorrhage. Its primary purpose is 30-day mortality prediction. It gives clinicians a fast, bedside tool to communicate prognosis to families and guide decisions about triage, transfer to a comprehensive stroke center, and goals of care.
A key caveat upfront: multiple authoritative sources emphasize that the ICH score must not be used to withhold care prematurely. Current guidelines recommend full support for at least 72 hours in most patients to avoid a self-fulfilling prophecy - studies have shown these scores were developed on historical cohorts where the clinicians designing the score also cared for the same patients, creating a real risk of bias. - Plum and Posner's Diagnosis and Treatment of Stupor and Coma; Goldman-Cecil Medicine
The Five Components
The ICH score has a maximum of 6 points (range 0-6). Higher scores = higher predicted mortality.
1. Glasgow Coma Scale (GCS) - up to 2 points
This is the single most heavily weighted component.
| GCS at Presentation | Points |
|---|---|
| 3-4 (deep coma / near-brain-dead) | 2 |
| 5-12 (stuporous to semi-comatose) | 1 |
| 13-15 (alert or only mildly impaired) | 0 |
Why GCS matters so much: Level of consciousness at presentation reflects the volume and location of the bleed, degree of mass effect, and whether herniation is occurring. A GCS of 3-4 represents near-complete brainstem failure and earns the maximum 2 points - already putting the patient at very high risk before any other factor is added.
2. ICH Volume - 1 point
| Volume | Points |
|---|---|
| ≥ 30 mL | 1 |
| < 30 mL | 0 |
How to measure ICH volume on CT (the ABC/2 method):
This is calculated directly from the non-contrast head CT:
- Find the CT slice showing the largest cross-sectional area of the hematoma.
- Measure A = longest diameter of the hematoma on that slice (in cm).
- Measure B = longest diameter perpendicular to A on the same slice (in cm).
- Count C = number of slices on which blood is visible, multiplied by the slice thickness (in cm) - this gives the depth in cm.
- Apply the formula: Volume = (A × B × C) / 2
This gives volume in mL (or cm³, same thing). The cutoff is 30 mL. A volume ≥ 30 mL is associated with higher mass effect, greater midline shift, and worse outcome. Volumes ≥ 60 mL with a GCS ≤ 8 are associated with very high mortality. - Adams and Victor's Principles of Neurology, 12th ed.
3. Intraventricular Hemorrhage (IVH) - 1 point
| IVH Present? | Points |
|---|---|
| Yes | 1 |
| No | 0 |
What is it: Blood extending from the parenchymal bleed into the ventricular system. On CT it appears as hyperdense (white) material within the ventricles - most commonly the lateral ventricles, but can extend to the third and fourth ventricles.
Why it matters: IVH causes obstructive hydrocephalus by blocking CSF outflow. It is a marker of bleed extension and indicates a larger, more aggressive hemorrhage. It is also independently associated with worse outcomes and often requires emergent external ventricular drain (EVD) placement. - Plum and Posner's
4. Infratentorial Origin - 1 point
| Location | Points |
|---|---|
| Infratentorial (cerebellum or brainstem) | 1 |
| Supratentorial | 0 |
What counts as infratentorial: Any hemorrhage in the posterior fossa - the cerebellum, pons, midbrain, or medulla.
Why it's penalized: Infratentorial hemorrhages are especially dangerous because:
- The posterior fossa has very limited space - even a small bleed causes rapid brainstem compression.
- Brainstem hemorrhages directly injure respiratory and cardiovascular control centers.
- Cerebellar hemorrhages can rapidly progress from ataxia to stupor and coma as the brainstem is compressed.
- These are often surgical emergencies - immediate evacuation is recommended for cerebellar hemorrhages ≥ 15 mL with brainstem compression or hydrocephalus. - Goldman-Cecil Medicine
5. Age ≥ 80 Years - 1 point
| Age | Points |
|---|---|
| ≥ 80 years | 1 |
| < 80 years | 0 |
Why age 80 is the cutoff: Older patients have less cerebral reserve, more pre-existing white matter disease (leukoaraiosis), greater likelihood of cerebral amyloid angiopathy as the bleeding cause, worse tolerance of surgical intervention, and more comorbidities. This threshold was empirically derived from the original validation cohort.
Scoring Summary Table
| Component | Finding | Points |
|---|---|---|
| GCS | 3-4 | 2 |
| GCS | 5-12 | 1 |
| GCS | 13-15 | 0 |
| ICH Volume | ≥ 30 mL | 1 |
| ICH Volume | < 30 mL | 0 |
| Intraventricular hemorrhage | Yes | 1 |
| Intraventricular hemorrhage | No | 0 |
| Infratentorial location | Yes | 1 |
| Infratentorial location | No | 0 |
| Age | ≥ 80 years | 1 |
| Age | < 80 years | 0 |
| Maximum possible | 6 |
Predicted 30-Day Mortality by Score
| ICH Score | Estimated 30-Day Mortality |
|---|---|
| 0 | 0% |
| 1 | 13% |
| 2 | 26% |
| 3 | 72% |
| 4 | 97% |
| 5+ | 100% |
Source: Hemphill et al. 2001; confirmed in Goldman-Cecil Medicine and Adams and Victor's Principles of Neurology.
A score of 0 (alert patient, small bleed, supratentorial, age < 80, no IVH) has essentially zero predicted mortality. A score of 4 or 5 is nearly uniformly fatal.
Worked Examples
Case A: 65-year-old patient, GCS 14, CT shows a 20 mL left putaminal hemorrhage with no IVH, no posterior fossa involvement.
- GCS 13-15 = 0
- Volume < 30 mL = 0
- No IVH = 0
- Supratentorial = 0
- Age < 80 = 0
- ICH Score = 0 → ~0% predicted 30-day mortality. Good prognosis, expect reasonable recovery.
Case B: 82-year-old patient, GCS 8, CT shows a 45 mL right thalamic hemorrhage with IVH and hydrocephalus, supratentorial.
- GCS 5-12 = 1
- Volume ≥ 30 mL = 1
- IVH present = 1
- Supratentorial = 0
- Age ≥ 80 = 1
- ICH Score = 4 → ~97% predicted 30-day mortality. Extremely guarded prognosis; goals-of-care discussion is essential.
Case C: 55-year-old patient, GCS 6, CT shows a 12 mL cerebellar hemorrhage with brainstem compression, no IVH.
- GCS 5-12 = 1
- Volume < 30 mL = 0
- No IVH = 0
- Infratentorial = 1
- Age < 80 = 0
- ICH Score = 2 → ~26% predicted 30-day mortality. However, this patient also meets criteria for urgent surgical evacuation (cerebellar bleed with brainstem compression) regardless of score.
Limitations and Important Caveats
-
Self-fulfilling prophecy risk: If clinicians use the score to justify early withdrawal of care, patients who might survive die because of the decision to stop treatment, which then "validates" the score. Multiple textbooks and the 2024 Neurocritical Care Society guidelines (PMID: 37923968) emphasize this problem explicitly.
-
The score predicts mortality, not functional outcome. A patient with an ICH score of 3 who survives may still have significant disability. The FUNC score (range 0-11) was developed specifically to predict functional independence at 90 days and is often used alongside the ICH score.
-
No treatment information is built in. The score was derived before modern interventions like minimally invasive surgery, aggressive blood pressure management, and anticoagulant reversal agents were widely used.
-
It was validated primarily in hypertensive hemorrhage - its performance may differ in hemorrhages from other causes (amyloid angiopathy, AVM, coagulopathy).
The FUNC Score (Brief Comparison)
Since clinicians often use both together:
| Component | Points |
|---|---|
| GCS ≥ 9 | 2 |
| GCS < 9 | 0 |
| ICH volume < 30 mL | 4 |
| ICH volume 30-60 mL | 2 |
| ICH volume ≥ 60 mL | 0 |
| Age < 70 | 2 |
| Age 70-79 | 1 |
| Age ≥ 80 | 0 |
| Lobar location | 2 |
| Deep location | 1 |
| Infratentorial | 0 |
| No pre-ICH cognitive impairment | 1 |
| Pre-ICH cognitive impairment | 0 |
FUNC score range: 0-11. A FUNC score of 0-4 predicts 0% functional independence at 90 days; a score of 11 predicts 82% functional independence. - Adams and Victor's Principles of Neurology, 12th ed.
Clinical Workflow Summary
- Get a non-contrast CT head immediately in any suspected ICH.
- Calculate GCS at presentation (before sedation if possible).
- Measure ICH volume using the ABC/2 method on CT.
- Note location (infratentorial vs. supratentorial).
- Check for IVH on CT.
- Record patient age.
- Add the points to get the ICH score.
- Use the score to guide prognosis discussions with family - never to unilaterally withdraw care.
- Maintain full support for at least 72 hours in most cases per current guidelines.
Sources:
- Adams and Victor's Principles of Neurology, 12th Ed., Table 33-9
- Goldman-Cecil Medicine, Table 377-7
- Plum and Posner's Diagnosis and Treatment of Stupor and Coma, Table 8.2
- Hemphill JC 3rd et al. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. [Stroke 2001;32:891-897]
- 2024 Neurocritical Care Society Neuroprognostication Guidelines (PMID: 37923968) - Systematic Review & Practice Guideline
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