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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.
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%
- 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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
Rounding and precision effects
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.
| 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 |
What does the ICH Score predict?
In the context of Intracerebral Haemorrhage Score, this depends on the specific inputs, assumptions, and goals of the user. The underlying formula provides a deterministic relationship between inputs and output, but real-world application requires interpreting the result within the broader context of health and medical practice. Professionals typically cross-reference calculator output with industry benchmarks, historical data, and regulatory requirements. For the most reliable results, ensure inputs are sourced from verified data, understand which assumptions the formula makes, and consider running multiple scenarios to bracket the range of likely outcomes.
Why does ICH Score 0 have 0% mortality?
In the context of Intracerebral Haemorrhage Score, this depends on the specific inputs, assumptions, and goals of the user. The underlying formula provides a deterministic relationship between inputs and output, but real-world application requires interpreting the result within the broader context of health and medical practice. Professionals typically cross-reference calculator output with industry benchmarks, historical data, and regulatory requirements. For the most reliable results, ensure inputs are sourced from verified data, understand which assumptions the formula makes, and consider running multiple scenarios to bracket the range of likely outcomes.
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.
Why does infratentorial origin score 1 point?
In the context of Intracerebral Haemorrhage Score, this depends on the specific inputs, assumptions, and goals of the user. The underlying formula provides a deterministic relationship between inputs and output, but real-world application requires interpreting the result within the broader context of health and medical practice. Professionals typically cross-reference calculator output with industry benchmarks, historical data, and regulatory requirements. For the most reliable results, ensure inputs are sourced from verified data, understand which assumptions the formula makes, and consider running multiple scenarios to bracket the range of likely outcomes.
Is surgical evacuation recommended for high ICH Scores?
In the context of Intracerebral Haemorrhage Score, this depends on the specific inputs, assumptions, and goals of the user. The underlying formula provides a deterministic relationship between inputs and output, but real-world application requires interpreting the result within the broader context of health and medical practice. Professionals typically cross-reference calculator output with industry benchmarks, historical data, and regulatory requirements. For the most reliable results, ensure inputs are sourced from verified data, understand which assumptions the formula makes, and consider running multiple scenarios to bracket the range of likely outcomes.
What is the difference between ICH Score and FUNC Score?
In the context of Intracerebral Haemorrhage Score, this depends on the specific inputs, assumptions, and goals of the user. The underlying formula provides a deterministic relationship between inputs and output, but real-world application requires interpreting the result within the broader context of health and medical practice. Professionals typically cross-reference calculator output with industry benchmarks, historical data, and regulatory requirements. For the most reliable results, ensure inputs are sourced from verified data, understand which assumptions the formula makes, and consider running multiple scenarios to bracket the range of likely outcomes.
Pro Tip
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.
Did you know?
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.
References
- ›Hemphill JC et al. The ICH Score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 2001.
- ›Broderick JP et al. AHA/ASA Guidelines for the Management of Spontaneous ICH. Stroke 2007.
- ›Morgenstern LB et al. 2010 AHA/ASA Guidelines for ICH. Stroke 2010.
- ›Zahuranec DB et al. Early care limitations independently predict mortality after ICH. Neurology 2007.
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