Calculate the Intracerebral Hemorrhage (ICH) score to predict 30-day and 12-month mortality from GCS, volume, IVH, location, and age.
The Intracerebral Hemorrhage (ICH) Score is one of the most widely used clinical grading scales for predicting mortality after spontaneous intracerebral hemorrhage, the deadliest form of stroke with 30-day mortality rates of 30-50%. Developed by J. Claude Hemphill III and colleagues in 2001, this 6-point scale integrates five independent predictors of ICH mortality into a simple bedside tool.
The five components—Glasgow Coma Scale score, ICH volume, intraventricular hemorrhage extension, infratentorial location, and age ≥ 80 years—were identified through multivariate analysis of a prospective cohort. The ICH score demonstrates excellent discrimination with a stepwise increase in 30-day mortality from 0% (score 0) to 100% (score 5-6).
This calculator computes the ICH score with detailed component scoring, provides 30-day and 12-month mortality estimates, suggests ICU admission and surgical considerations, and includes important caveats about self-fulfilling prophecy bias—the phenomenon where early withdrawal of care based on prognostic scores artificially validates those score's mortality predictions.
The ICH score provides standardized, rapid mortality prognostication for hemorrhagic stroke patients, facilitating family communication, resource allocation, and treatment planning while emphasizing that prognostic scores should inform but not dictate care decisions. Keep these notes focused on your operational context. Tie the context to the calculator’s intended domain. Use this clarification to avoid ambiguous interpretation.
ICH Score = GCS points (3-4: 2pts, 5-12: 1pt, 13-15: 0pts) + Volume (≥30cm³: 1pt) + IVH (yes: 1pt) + Infratentorial (yes: 1pt) + Age ≥80 (yes: 1pt). Range: 0-6. 30-day mortality: 0pts=0%, 1pt=13%, 2pts=26%, 3pts=72%, 4pts=97%, 5-6pts=100%.
Result: ICH Score: 0 — 0% 30-day mortality
All five components score 0, yielding a total ICH score of 0 with 0% observed 30-day mortality in the original cohort. This represents the most favorable prognosis category.
One of the most critical considerations in ICH prognostication is the self-fulfilling prophecy effect. Studies have shown that early withdrawal of care based on prognostic scores is the single strongest predictor of mortality in ICH—more predictive than the clinical variables themselves. Patients who receive aggressive, sustained care may have significantly better outcomes than prognostic models predict.
Modern ICH management focuses on several key interventions: aggressive blood pressure reduction (SBP < 140 mmHg within 1 hour per INTERACT2/ATACH-2), rapid anticoagulation reversal if applicable, monitoring for hematoma expansion (repeat CT at 6 hours), ICP management with EVD placement for hydrocephalus, and neurosurgical consultation for posterior fossa hemorrhages. The MISTIE III trial showed potential benefit for minimally invasive surgery in selected patients.
While the original ICH score remains the most widely used, newer tools like the FUNC score (predicting functional independence), the max-ICH score (incorporating oral anticoagulation), and machine learning models incorporating CT perfusion data may provide more nuanced prognostication. These tools complement rather than replace the ICH score in clinical practice.
The ICH score is a validated clinical grading scale that predicts 30-day mortality after spontaneous intracerebral hemorrhage using five easily assessed variables: GCS, hemorrhage volume, IVH, infratentorial location, and age. Use this as a practical reminder before finalizing the result.
ICH volume is most commonly estimated using the ABC/2 method on CT: A (largest diameter) × B (perpendicular diameter on same slice) × C (number of slices with hemorrhage × slice thickness) / 2. This approximation correlates well with volumetric measurements.
No. The ICH score should NEVER be used as the sole basis for limiting care. Self-fulfilling prophecy bias is well-documented: early care withdrawal based on prognostic scores increases observed mortality, artificially validating the score. All patients deserve full initial stabilization.
IVH refers to blood extending into the brain ventricles, which is associated with worse outcomes due to obstructive hydrocephalus, inflammation, and additional brain injury. IVH is present in approximately 45% of ICH cases.
Posterior fossa hemorrhages (brainstem, cerebellum) carry higher mortality because even small volumes can compress critical brainstem structures and cause rapid deterioration. Surgical evacuation is often considered for cerebellar hemorrhages > 3 cm.
Anticoagulation-related ICH has higher mortality due to hematoma expansion. Urgent reversal is critical: 4-factor PCC for warfarin, idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors. Consider adding 1 point to the ICH score for patients on anticoagulation.