The ICH Score: What It Is and What It Is Not 1).
The ICH Score has become the standard for risk-stratification of 30-d mortality in patients with intracerebral hemorrhage (ICH), but treatment has evolved over the last 17 yr since its inception.
The ICH score is a useful tool for predicting 30-day mortality both in patient who use and patients who do not use OAC. Although OAC use is an independent predictor of 30-day mortality, addition of OAC use to the existing ICH score does not increase the prognostic performance of this score 2)
The ICH Score is the sum of individual points assigned as follows:
GCS score 3 to 4 (=2 points),
5 to 12 (=1),
13 to 15 (=0)
Age >/=80 years yes (=1), no (=0);
Infratentorial origin yes (=1), no (=0);
ICH volume >/=30 cm(3) (=1), <30 cm(3) (=0);
Intraventricular hemorrhage yes (=1), no (=0).
Patient 68 years old GCS 4: ICH 4 score
All 26 patients with an ICH Score of 0 survived, and all 6 patients with an ICH Score of 5 died. Thirty-day mortality increased steadily with ICH Score (P<0.005) 3).
Malinova et al. evaluated the reproducibility of the ICH-score in ICH patients undergoing fibrinolytic therapy.
They performed a retrospective analysis of patients with supratentorial ICH managed by fibrinolytic therapy and evaluated the 30-day mortality. The ICH-score was then applied to match the mortality in the patients with the mortality predicted by the ICH-score. The ICH-score is based on parameters available at admission: age, hematoma volume, intraventricular expansion, and clinical status according to the Glasgow Coma Scale.
A total of 233 patients were analyzed. The 30-day mortality rate was 30% (70/233). An age of ≥80 years was associated with a significantly higher mortality rate (OR 2.26, chi-square test p = 0.01). A hematoma volume of ≥30 mL led significantly more often to 30-day mortality (OR 3.72, chi-square test p = 0.01). The mortality was significantly higher in patients with intraventricular hemorrhage (2.97, chi-square test p = 0.003). The ICH-score showed a significant correlation with mortality (chi-square test, p < 0.0001). The following mortality rates were estimated using the ICH-score in our cohort: 1 = 0% (0/13), 2 = 0% (0/51), 3 = 1.3% (1/82), 4 = 43% (13/31), 5 = 100% (56/56). : The ICH-score not only allowed a reliable estimation of the 30-day mortality in patients with ICH treated conservatively but also treated by clot lysis. Compared to conservative treatment, fibrinolytic therapy reduced the 30-day mortality in patients with ICH-scores 1-4. Patients with ICH-score 5 do not have a benefit of fibrinolytic therapy and should no longer be considered to be candidates for fibrinolytic therapy 4).
The original ICH score did not accurately predict the mortality rate in the series of the Department of Neurosurgery, Emory University, Atlanta, Georgia. Patient survival exceeded ICH Score-predicted mortality regardless of surgical intervention. Reevaluation of predictive scores could be useful to aid in more accurate prognoses 5).
A caveat about overreliance on grading systems, especially early in the course, bears discussion. In an effort to apply an evidence-based methodology to the care of the ICH patient, a number of prognostic models have been developed. While they are helpful, their development may have been biased by self-fulfilling prophecies based on the withdrawal of medical support in the face of apparently devastating neurologic injury. The American Heart Association statement on “Palliative and End-of-Life Care in Stroke” discusses palliative care, and it is recommended that in the absence of known preexisting DNR wishes, the decision to withdraw support not be made until at least the second full day of hospitalization after ICH (Level II).