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    Patent Pending

    Secondary Intracerebral Hemorrhage (sICH) Score

    Quantifies likelihood of underlying vascular etiology in patients with ICH.
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    When to Use
    Pearls/Pitfalls
    Why Use

    Patients with ICH who have had non-contrast CT (NCCT).

    • The Secondary ICH (sICH) Score predicts likelihood that a given ICH is secondary to an underlying vascular abnormality, based on clinical and radiographic characteristics.
    • Should not be used for patients with any of the following:
      • Subarachnoid hemorrhage in the basal cisterns.
      • Clear-cut, pre-established acute ischemic infarct with secondary hemorrhage within the area of infarct.
      • Known intracranial vascular abnormality or mass lesion.
      • Known probable cerebral amyloid angiopathy per Boston criteria.
    • Does not predict morbidity or mortality in ICH.
    • Difference in discriminatory according to imaging interpretations by neurologists vs. radiologists has not been determined.
    • Can help stratify which patients with ICH should undergo CT angiography (CTA) if CTA is not routinely performed for workup of ICH at specific institutions.
    • In select cases, can help determine which patients with ICH should undergo catheter angiogram (the risks of which include, but are not limited to, renal injury, pseudoaneurysm, and arterial dissection) for definitive evaluation for an underlying vascular abnormality.
    • May help with operative planning when emergent neurosurgery for ICH is indicated and either CTA or catheter angiogram cannot be done safely.

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    • Bear in mind that the sICH Score is an adjunct to, and not a substitute for, clinical judgment.
    • In a patient with sICH Score <2 and CTA negative for vascular abnormality, catheter angiogram may present greater procedural risks than benefits from identifying an underlying vascular etiology.
    • In selected patients with sICH Score >2 and CTA negative for vascular abnormality, catheter angiogram may be considered after careful weighing of procedural risks and benefits. Note that CTA is not the gold standard but remains a highly sensitive and specific imaging technique for detecting vascular abnormalities.

    Management

    • ICH is a neurological emergency. Immediate neurological and neurosurgical consultation should be obtained on patients with evidence of any ICH on imaging.
    • Hypertensive patients with acute ICH should undergo blood pressure reduction with intravenous agents. The target blood pressure should be discussed with the neurological or neurosurgical consultant.
    • The decision to administer reversal agents (e.g. desmopressin) blood products (e.g. prothrombin factor concentrate, fresh frozen plasma), or anti-epileptic medications should not be made without discussing with the neurological or neurosurgical consultant.
    • Platelet administration is NOT recommended in the setting of antiplatelet-related ICH.

    Critical Actions

    It is crucial to identify and reverse anticoagulant-associated ICH (using agents tailored to the underlying anticoagulant).

    Formula

    Addition of the selected points:

    Parameter

    0 points

    1 point

    2 points

    Probability by NCCT Categorization



    Low

    Indeterminate

    High

    No high-probability criteria present

    OR

    Basal ganglia, thalamus, or brainstem location

    No high or low probability features present

    Enlarged vessels or calcifications along margins of ICH

    OR

    Hyperattenuation within dural venous sinus or cortical vein along the path of drainage of ICH

    Age

    ≥71 years

    46-70 years

    18-45 years

    Sex

    Male

    Female

    --

    Absence of both HTN AND impaired coagulation*

    No

    Yes

    --

    *Defined as admission INR >3, aPTT >80 seconds, platelet count <50,000, or daily antiplatelet therapy.

    Facts & Figures

    Interpretation:

    sICH Score

    % Positive CTA*

    0

    0

    1

    1.5

    2

    4.4

    3

    20

    4

    38.1

    5

    80

    6

    100

    For siCH Score >2, sensitivity: 85.8%, specificity: 72.3%.

    *CTA showing vascular abnormality, in prospective validation cohort from Almandoz 2010.

    Evidence Appraisal

    The sICH Score was developed by Almandoz et al in 2010 based on retrospective derivation (n = 623) and prospective validation (n = 222) cohorts. In this study, AUCs were not significantly different between derivation and validation cohorts, and the AUC for the combined cohort was 0.87 (95% CI 0.84–0.89), with a cut-point of >2 corresponding to 86% sensitivity and 72% specificity (p<0.0001). The study was limited by the use of a retrospective derivation cohort, as well as selection bias from only including patients with ICH that ultimately underwent CTA.

    Because CTA was originally used to determine presence of vascular abnormality, the sICH was then validated by the same group in 2012 in a retrospective cohort (n = 341) using catheter angiography or intraoperative findings. Again, higher sICH scores were associated with increasing likelihood of harboring an underlying vascular etiology as follows:

    • sICH 0: 0% positive cases
    • sICH 1: 1.6%
    • sICH 2: 7.8%
    • sICH 3: 18.8%
    • sICH 4: 39.0%
    • sICH 5: 79.2%

    AUC in this study was 0.82 with a cut-point of >2 corresponding to sensitivity and specificity of 82% and 66.1%, respectively.

    Literature

    Dr. Josser Delgado Almandoz

    About the Creator

    Josser Delgado Almandoz, MD, is a consulting neuroradiologist at Abbott Northwestern Hospital in Minneapolis, MN. He is an active researcher on topics including stroke intervention and other intracranial disease. He was a contributing author to the Training Guidelines for Endovascular Ischemic Stroke Intervention: An International Multi-Society Consensus Document, a consensus on stroke treatment training of 10 neurological disease societies around the world.

    To view Dr. Josser Delgado Almandoz's publications, visit PubMed

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