ICH Score
The ICH Score predicts 30-day mortality after intracerebral haemorrhage using five readily available clinical and radiographic features: GCS, ICH volume, presence of IVH, infratentorial origin, and age ≥80.
inputs
✓ when to use
Use after CT-confirmed intracerebral haemorrhage to estimate 30-day mortality and guide goals-of-care discussions. Helps communicate prognosis to families and inform treatment escalation decisions.
✗ when not to use
The ICH Score predicts mortality, not functional outcome in survivors. Self-fulfilling prophecy bias is a major concern: high ICH scores may lead to withdrawal of aggressive care, which itself increases mortality. The score should inform discussion, not dictate care withdrawal. Not validated for traumatic ICH or haemorrhagic transformation of ischaemic stroke.
clinical pearls
- The biggest risk with the ICH Score is self-fulfilling prophecy. If a high score leads clinicians to withdraw aggressive care early, the mortality prediction becomes artificially accurate. Use the score for counselling, not as a sole determinant of care intensity.
- ICH volume is estimated using the ABC/2 method on CT: A = largest diameter, B = perpendicular diameter, C = number of slices × slice thickness, divide by 2. This is an approximation but correlates well with planimetric volume.
- Infratentorial (posterior fossa) ICH carries disproportionate risk due to brainstem compression and hydrocephalus, independent of volume. A 15 mL cerebellar haemorrhage is far more dangerous than a 15 mL lobar haemorrhage.
- IVH (blood in the ventricles) is an independent predictor of poor outcome because it causes obstructive hydrocephalus. External ventricular drain (EVD) placement may be needed.
- Recent trials (INTERACT2, ATACH-2) have refined ICH management. Intensive BP lowering (target SBP <140) within 6 hours, rapid reversal of anticoagulation, and consideration of minimally invasive surgery are all evolving areas.