Intracerebral hemorrhage (ICH) is a severe form of stroke resulting from bleeding directly into the brain tissue, which can sometimes extend into the brain’s ventricular system. This sudden accumulation of blood creates a mass that compresses surrounding brain matter, disrupting function and increasing pressure inside the skull. Although ICH accounts for only 10% to 15% of all strokes, it is associated with a high rate of severe disability and death. Since rapid deterioration often occurs within the first 48 hours, a quick, reliable method is necessary to assess the severity of the injury. Standardized grading systems allow emergency medical teams to communicate the patient’s condition clearly and uniformly for rapid triage and treatment planning.
Identifying the Intracerebral Hemorrhage Score
The Intracerebral Hemorrhage Score (ICH Score) is the most widely adopted and validated tool for assessing prognosis in patients with spontaneous ICH. Established in 2001, this simple clinical grading scale remains a standard component of initial evaluation in neurocritical care settings worldwide. The primary function of the ICH Score is to provide a rapid, objective assessment that predicts a patient’s risk of 30-day mortality. By using easily obtainable clinical and radiological factors, the score allows physicians to stratify risk, guide discussions regarding outcome, and ensure consistency in clinical research studies. The ICH Score is a cumulative system where points are assigned for specific risk factors, resulting in a total score that ranges from 0 to 6, where a higher score correlates directly with a worse prognosis.
Factors Used in Score Calculation
The ICH Score is calculated by summing the points from five individual components, each of which has been independently identified as a strong predictor of poor outcome. The patient’s level of consciousness upon arrival is assessed using the Glasgow Coma Scale, or GCS, a standardized neurological tool that measures eye-opening, verbal response, and motor response. A GCS score between 13 and 15 is considered mild impairment and assigns 0 points to the ICH Score, while a GCS between 5 and 12 indicates moderate impairment and adds 1 point. The most severe impairment, a GCS score of 3 or 4, represents a deeply comatose state and contributes 2 points to the total score.
The physical size of the hemorrhage, known as the ICH volume, is another factor that is quantified from the initial CT scan. A smaller hemorrhage, defined as a volume less than 30 cubic centimeters (cm³), is assigned 0 points, whereas a larger hemorrhage of 30 cm³ or more adds 1 point. This volume is often estimated quickly in the emergency setting using the ABC/2 method. The ICH volume is a highly significant predictor because larger bleeds cause more mass effect and tissue destruction.
The location of the hemorrhage also contributes to the score, specifically whether the bleeding is in the infratentorial region, which includes the brainstem and cerebellum. Bleeding in this area adds 1 point to the score, while all other locations add 0 points. The presence of blood extension into the brain’s fluid-filled cavities, known as intraventricular hemorrhage (IVH), is a significant negative predictor. Because IVH can obstruct normal cerebrospinal fluid flow and cause a dangerous buildup of pressure, its presence is a significant negative predictor and adds 1 point to the ICH Score.
Finally, advanced age is factored in. Patients under 80 years old are assigned 0 points, and those aged 80 years or older are assigned 1 point. This factor is included because physiological changes reduce the brain’s ability to tolerate injury and recover.
Interpreting the Score and Prognosis
The final ICH Score, the sum of the five factors, provides a prognostic estimate for the patient’s likelihood of death within 30 days. A total score of 0, representing the most favorable clinical and radiological profile, is associated with a 30-day mortality rate of 0%. As the score increases by a single point, the risk of death rises significantly.
A score of 1 suggests a 30-day mortality rate of approximately 13%, and a score of 2 increases this risk to about 26%. A score of 3 correlates with a mortality rate of around 72%, while a score of 4 correlates with a mortality rate of nearly 97%. The highest possible scores, 5 and 6, are associated with a mortality rate of 100%.
Beyond predicting mortality, the ICH Score also serves as a strong indicator of functional outcome for survivors. Patients with lower scores are much more likely to achieve functional independence. Conversely, those with higher scores face a poor functional prognosis, with a lower likelihood of recovering the ability to perform daily activities. Only about 20% are expected to be functionally independent six months after the event. The interpretation of the total ICH Score provides a clear framework for anticipating both short-term survival and long-term functional recovery.