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    Intracerebral Hemorrhage (ICH) Score

    Based on age and CT findings; estimates mortality.
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    When to Use
    Pearls/Pitfalls
    Why Use
    • The ICH score allows for a standardized and consistent clinical grading scale for ICH, thus improving communication among clinicians.
    • The ICH score grades ICH severity and subsequent 30-day mortality, thus helping to guide goals of care conversations with patients’ families.
    • This score is often used in conjunction with the FUNC score, which indicates the likelihood of a patient’s functional independence 90 days after ICH.
    • While the score can be a marker for ICH severity, it is typically not used to guide treatment modality.
    • The ICH Score allows clinicians with varying level of training and clinical backgrounds to grade ICH severity in a succinct, universal manner.
    • The ICH Score is intended to be used after the diagnosis of ICH is made, and is generally not used as a continual marker of the patient’s neurologic status (such as the GCS).
    • The score is sometimes criticized as physicians and families had previously used gestalt to make the decision to withdraw care, and that this bias may have affected the validation.
    • Please note that the ICH score is primarily used as a clinical grading scale and communication tool. It is not meant to provide prognostic information, and should not be used as a primary means to predict the outcomes of patients with ICH.

    This tool helps clinicians quickly and accurately prognosticate patients who are admitted for ICH, and can be used as a tool to help decide the appropriate level of care and/or transfer.

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    Advice

    • While the ICH score grades severity of the disease, it does not directly affect treatment modalities.
    • Patients with intracerebral hemorrhage should have emergent consultation with neurosurgery and stabilized prior to transfer, if transfer is required. Most patients require ICU-level care and monitoring for airway sequelae of neurologic decompensation.
    • ICH often causes hydrocephalus, thus patients with low GCS and/or signs of hydrocephalus on Head CT may also need urgent ventricular decompression with an extra-ventricular drain (EVD).
    • Coagulation studies should be ordered immediately to determine if there is any coagulopathy that is contributing to ongoing bleeding. Clinicians should also determine if aspirin was taken by the patient, as this may require platelet transfusion to help achieve hemostasis.
    • AHA guidelines recommend lowering systolic BP to < 160 mmHg, usually achieved with IV antihypertensives.

    Management

    Clinical decisions regarding goals of care should not be made solely based on ICH score. Other factors such as patients’ and families’ wishes, baseline neurologic status, and other co-morbidities should be taken into consideration.

    Critical Actions

    • Attention should be paid to patients on anti-platelet agents or anticoagulation as often these patients require reversal agents.
    • Patient’s with ICH should be emergently transferred to a facility with neurosurgical capabilities if not present at the admitted facility.

    Facts & Figures

    Score interpretation:

    ICH Score Mortality Rate
    0 0%
    1 13%
    2 26%
    3 72%
    4 94%
    5 100%
    6* 100%

    *No patients in study score 6, but estimates 100%

    Evidence Appraisal

    The ICH score was developed to provide a clinical grading scale for ICH that helps standardize clinical treatment protocols and clinical research studies in ICH. The score was developed at UCSF, with the original study analyzing 161 patients presenting with ICH to UCSF between 1997-1998. Overall, the analysis helps provide information about the degree of severity of ICH as well as 30-day mortality rates that helped guide decision-making.

    Dr. J. Claude Hemphill, III

    From the Creator

    Why did you develop the ICH Score? Was there a clinical experience that inspired you to create this tool for clinicians?
    The ICH Score was developed as a clinical grading scale and communication tool. As a young neurointensivist, I noticed that we used clinical grading scales for communication across providers regarding traumatic brain injury (GCS), ischemic stroke (NIHSS), subarachnoid hemorrhage (Hunt-Hess and WFNS), and AVM (Spetzler-Martin), but we did not have a standard way to communicate about ICH. Thus, I hoped for something informative yet simple and easy to determine. It was never intended to be used as a formal prognostic outcome prediction model.
    What pearls, pitfalls and/or tips do you have for users of the ICH Score? Are there cases in which it has been applied, interpreted, or used inappropriately?
    I have been overall surprised and disappointed at how many people have used the point estimates from the original ICH Score publication to presumably predict outcome and to communicate that to patients and their families. Ironically, in the first draft of the manuscript, I did not even include these numbers, just an overall graph. But one of the reviewers demanded they be put in and, as a young investigator wanting to get published, I complied. It has been extremely disappointing when I hear that physicians have chosen to not treat a patient aggressively or transfer to a higher level of care hospital because of a high ICH Score. I actually recall a conversation at the International Stroke Conference around 2003, when an ED physician in a community hospital thanked me for developing the ICH Score, because now he had a reason to avoid accepting transfers from smaller community hospitals for patients with ICH Scores of 4 or higher because they would always do poorly. This saddened me. Ironically this concern led me and others to the study of the self-fulfilling prophecy of poor outcome in ICH and other neurocritical care conditions if early DNR or withdrawal of support is undertaken. And this has hopefully overall increased the emphasis on aggressive care for ICH and other conditions such as TBI, SAH, and cardiac arrest.
    What recommendations do you have for health care providers once they have applied the ICH Score? Are there any adjustments or updates you would make to the score given recent changes in medicine?
    Utilize the ICH Score and other clinical grading scales for their intended use. Patient stratification and communication among providers and with patients and surrogates. But do not hang your hat on the point estimates. I certainly hope that the editors and users of MDCalc are not doing this. We do not assign a specific mortality risk to a GCS of 6 in TBI or a Hunt-Hess score of 3. Don't do it for the ICH Score either. Numerous studies have shown two things regarding the ICH Score: it is valid as an overall scale (meaning a 4 is worse than a 3 is worse than a 2, etc.) and the point estimates are confounded by early care limitations. And if you just can't help yourself, then use confidence intervals. But overall avoid the incorrect temptation to use any mathematical developed on a population of patients as a way to precisely predict outcome for the purposes of clinical decision-making in an individual patient I remain surprised at how many investigators continue on this false quest in ICH, SAH, and other conditions.
    As the ICH Score has become more widely adopted, do you anticipate further uses of the score?
    The American Heart Association is emphasizing the use of a baseline severity score as part of the initial evaluation of ICH patients. And the Joint Commission requires this for comprehensive stroke centers. This is overall a good thing for standardization. The ICH Score is one of these scales and is probably the most widely used and validated. So use it, but as intended.
    What are the main differences you see between the ICH score and FUNC score? In your mind, how can the two be used together to help clinicians?
    The FUNC score is focused on functional independence and, I think, is overall intended as more of a prediction tool. I would leave the issue of point estimate validity to the FUNC score authors. But I think they can be used in conjunction to provide a communication tool for providers and give an overall sense of ICH severity.
    Other comments? Any new research or papers on this topic in the pipeline?
    Take a look at the study we published last year that addresses some of the concerns above. Morgenstern, L. B., et al. (2015). Full medical support for intracerebral hemorrhage. Neurology 84(17): 1739-1744. And as always, use the ICH Guidelines as a framework for aggressive care of the ICH patient. Hemphill, J. C., 3rd, et al. (2015). Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 46(7): 2032-2060.
    It continues to humble me to see how, even without a “magic bullet,” there remains an art to being a good physician and aggressive care does matter. This is a very empowering message that should encourage us to identify the aspects of guideline-concordant care that improve patient outcomes.

    About the Creator

    J. Claude Hemphill, III, MD, MAS, is a professor of medicine and clinician in the Department of Neurology at the University of California, San Francisco. He is also the director of the Neurocritical Care Program at San Francisco General Hospital Medical Center. Dr. Hemphill cares for patients with stroke and traumatic brain injury and has a special research interest in intracerebral hemorrhage.

    To view Dr. J. Claude Hemphill, III's publications, visit PubMed

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