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ICH Calculator

Intracerebral hemorrhage (ICH) is bleeding within brain tissue that demands rapid clinical assessment. The ICH score quantifies severity using five key factors: patient age, Glasgow Coma Scale score, hematoma volume, intraventricular involvement, and hemorrhage origin. Clinicians use this score to estimate 30-day mortality and inform treatment decisions. This calculator translates those five parameters into a standardized risk grade, helping medical teams communicate prognosis and plan appropriate interventions.

Last updated:

Creators Adena Benn, BSc
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Understanding Intracerebral Hemorrhage

Intracerebral hemorrhage occurs when a blood vessel ruptures within the brain parenchyma or ventricular system, creating a localized collection of blood that damages surrounding tissue through mass effect and chemical irritation. Patients typically present with acute neurological deficits: sudden-onset headache, vomiting, decreased consciousness, seizures, and focal motor or sensory loss.

ICH accounts for 10–15% of all acute strokes and carries worse prognosis than ischemic stroke. Unlike ischemic events, no thrombolytic therapy reverses the damage; management focuses on stopping bleeding, controlling intracranial pressure, and preventing complications. The first 24–48 hours are critical, as ongoing hematoma expansion occurs in roughly 20% of patients.

Common Causes and Risk Factors

Chronic hypertension is the leading modifiable cause, accounting for 50–60% of cases. Other significant causes include:

  • Vascular malformations: arteriovenous malformations and cavernous angiomas
  • Coagulopathy: warfarin, direct oral anticoagulants, or inherited clotting disorders
  • Cerebral amyloid angiopathy: common in older adults, causes lobar bleeds
  • Aneurysm rupture: typically subarachnoid but can extend into brain tissue
  • Trauma: acute or chronic subdural hemorrhage from falls or head injury

Anticoagulation and antiplatelet therapy substantially increase bleeding risk in susceptible patients. Age over 60, history of prior ICH, and heavy alcohol use are additional independent risk factors.

ICH Score Calculation

The ICH score combines five clinical parameters, each contributing 0–2 points, to produce a total between 0 and 6. Higher scores indicate greater 30-day mortality risk. The scoring system was validated in a large prospective cohort and remains the most widely used bedside grading tool in acute neurology.

ICH Score = Glasgow Coma Scale points + Age points
+ ICH Volume points + Intraventricular points + Origin points

Glasgow Coma Scale (GCS):
GCS ≤ 4 → 2 points
GCS 5–12 → 1 point
GCS ≥ 13 → 0 points

Age:
≥ 80 years → 1 point
< 80 years → 0 points

ICH Volume:
≥ 30 mL → 1 point
< 30 mL → 0 points

Intraventricular blood:
Present → 1 point
Absent → 0 points

Hemorrhage origin (lobar vs. deep):
Infratentorial → 1 point
Supratentorial → 0 points

  • GCS — Glasgow Coma Scale score (3–15); measures depth of unconsciousness
  • Age — Patient age in years at time of hemorrhage
  • Volume — Hematoma volume in millilitres, measured on CT scan
  • Intraventricular — Presence of blood within the ventricular system
  • Origin — Anatomical location: supratentorial (above tentorium) or infratentorial (brainstem, cerebellum)

Interpreting the ICH Score and Mortality Rates

The ICH score predicts 30-day mortality with remarkable accuracy across diverse patient populations. A score of 0 corresponds to 0% mortality, while higher scores show exponential risk increase:

  • Score 1: 13% mortality
  • Score 2: 26% mortality
  • Score 3: 72% mortality
  • Score 4: 94% mortality
  • Score 5–6: 100% mortality

These figures should inform shared decision-making with families about prognosis and goals of care, though individual outcomes vary based on age, comorbidities, and quality of acute care. Patients with score 0–1 have substantially better functional recovery rates if they survive the acute phase.

Key Considerations When Using This Tool

The ICH score is a research-derived prognostication tool, not a treatment decision aid. Use it alongside clinical judgment.

  1. Timing of measurements matters — ICH volume expands during the first 24–48 hours in about 20% of patients. Early CT scans may underestimate final hematoma size, potentially lowering initial ICH scores. Repeat imaging and recalculation may be warranted as the clinical picture evolves.
  2. GCS can fluctuate rapidly — Glasgow Coma Scale scores reflect moment-to-moment consciousness and are sensitive to sedation, metabolic derangement, and drug effects. Scores obtained before stabilization or before correcting hypoglycaemia may not represent true neurological injury and should be re-assessed after medical optimization.
  3. ICH score does not guide intervention — A high ICH score does not automatically mandate limitations on aggressive care. Younger patients, those with reversible causes (e.g., anticoagulation reversal), and those with good premorbid function may still benefit from maximal medical and surgical intervention despite unfavourable predicted mortality.
  4. Functional outcome differs from mortality — The ICH score predicts 30-day death, not disability. Many survivors face severe neurological deficits. Discuss both mortality and long-term disability risk (using supplementary scales like the modified Rankin Score) when counseling families about prognosis and rehabilitation potential.

Frequently Asked Questions

What is the difference between ICH and ischaemic stroke?

Intracerebral haemorrhage results from rupture of a blood vessel, whereas ischaemic stroke occurs when a clot blocks blood flow to the brain. ICH accounts for 10–15% of strokes but carries higher mortality (around 40% at 30 days) and worse long-term disability. Ischaemic stroke allows for thrombolytic therapy within a narrow time window; ICH management focuses on controlling bleeding, reducing intracranial pressure, and preventing rebleeding. Imaging (CT scan) easily distinguishes the two, as blood appears bright white on non-contrast CT.

Can patients recover well from intracerebral hemorrhage?

Recovery depends heavily on ICH score, location, and volume. Patients with low ICH scores (0–1) have excellent survival and often good functional outcomes with rehabilitation. Those with moderate scores (2–3) may survive but face significant disability. High-score patients (4–6) rarely survive to hospital discharge. Location matters too: small deep-brain bleeds (basal ganglia, thalamus) often recover better than large lobar or infratentorial bleeds. Intensive care, early neurosurgical consultation, blood pressure control, and aggressive rehabilitation maximize recovery potential.

Why is the Glasgow Coma Scale score so important in ICH?

The GCS reflects the severity of brain injury and predicts neurological recovery. Scores below 5 indicate profound unconsciousness and likely severe brainstem injury, strongly associated with poor outcome. Even modest improvements in GCS (e.g., from 4 to 8) over hours to days signal neurological recovery and better prognosis. The scale is reproducible, easy to apply at the bedside, and widely used across neurology, intensive care, and trauma settings, making it a universal language for communicating brain injury severity.

Should anticoagulation be reversed in ICH patients?

Yes, when applicable. Patients on warfarin or direct oral anticoagulants (dabigatran, apixaban, rivaroxaban) should have anticoagulation reversed urgently with specific reversal agents (vitamin K, idarucizumab, idarucizumab) and fresh frozen plasma or prothrombin complex concentrates. Reversal reduces hematoma expansion and improves survival. However, reversal decisions must balance ICH severity against the patient's original indication for anticoagulation (e.g., atrial fibrillation, mechanical heart valve). Restarting anticoagulation is often essential once acute bleeding is controlled, requiring careful timing and shared decision-making.

What is the difference between supratentorial and infratentorial ICH?

The tentorium is a membrane separating the cerebellum and brainstem (infratentorial) from the cerebral hemispheres (supratentorial). Supratentorial bleeds (lobar, basal ganglia, thalamic) account for 80% of ICH. Infratentorial bleeds are less common but more immediately life-threatening because they compress the brainstem and block cerebrospinal fluid, causing acute hydrocephalus and herniation. Infratentorial ICH often requires emergency surgical drainage or ventriculostomy to decompress the posterior fossa. The ICH score gives 1 point to infratentorial origin due to this higher acute mortality risk.

How quickly does ICH expand after onset?

Hematoma expansion occurs in 20–30% of ICH patients, predominantly within the first 24–48 hours of symptom onset. Early expansion (within 6 hours) is most common and most dangerous, often accompanying rebleeding or coagulopathy. Rapid blood pressure elevation, anticoagulation use, and antiplatelet therapy increase expansion risk. Aggressive blood pressure control (target systolic <140 mmHg) and prompt reversal of anticoagulation reduce expansion rates. Repeat CT imaging at 24 hours helps detect unexpected growth and guides escalation of care or surgical intervention.

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