ICH Score Calculator — Intracerebral Hemorrhage Prognosis
The ICH (Intracerebral Hemorrhage) Score is a validated clinical grading scale that predicts 30-day mortality in patients with spontaneous intracerebral hemorrhage, based on five independent predictors: Glasgow Coma Scale score, age ≥80 years, infratentorial origin, ICH volume ≥30 mL, and intraventricular hemorrhage.
About
The ICH Score was developed by Hemphill et al. and published in Stroke in 2001. It was derived from a cohort of 161 patients with spontaneous ICH at the University of California, San Francisco. The score assigns 0-2 points for GCS (GCS 13-15 = 0, GCS 5-12 = 1, GCS 3-4 = 2) and 0-1 point for each of: age ≥80, infratentorial origin, ICH volume ≥30 mL, and intraventricular hemorrhage. Total scores range from 0-6, with each point increase associated with a stepwise increase in 30-day mortality: 0 (0%), 1 (13%), 2 (26%), 3 (72%), 4 (97%), and 5-6 (100%). The score has been externally validated in multiple cohorts worldwide and is widely used in clinical practice for prognostication, treatment decisions (including surgical candidacy), and clinical research. The original study reported an area under the ROC curve of 0.85 for 30-day mortality prediction.
Formula
GCS (0-2) + Age ≥80 (1) + Infratentorial (1) + ICH Volume ≥30 mL (1) + IVH (1). Total 0-6.
The ICH score is calculated by summing points from 5 components: (1) GCS score: 13-15 = 0 points, 5-12 = 1 point, 3-4 = 2 points. (2) Age ≥80 years: 1 point. (3) Infratentorial origin (cerebellar or brainstem): 1 point. (4) ICH volume ≥30 mL on initial CT (calculated using ABC/2 method): 1 point. (5) Intraventricular hemorrhage (IVH) present: 1 point. Total score 0-6. Each increasing point corresponds to higher 30-day mortality. The score is most useful for standardizing prognosis communication, identifying patients who may benefit from aggressive intervention (scores 1-2), and guiding goals-of-care discussions (scores 4-6).
Score Interpretation
The ICH Score is the most widely used prognostic scale for spontaneous intracerebral hemorrhage, endorsed in the AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. It provides a simple, rapid, and reproducible method for predicting 30-day mortality at the bedside using only clinical and initial CT findings. The score has been externally validated in over 10,000 patients across multiple international cohorts with consistent performance (AUC 0.82-0.92). Beyond mortality prediction, the ICH Score correlates with functional outcome at 30 days and 6 months, and higher scores (≥4) are associated with poor functional outcomes in >90% of survivors. The score is used to guide treatment decisions including the appropriateness of intensive care, surgical evacuation (particularly for cerebellar hemorrhages), and goals-of-care discussions. However, the ICH Score should not be used in isolation for withdrawal of care decisions, as it provides prognostic information at the population level and individual outcomes may vary. Other prognostic factors such as GCS score trajectory, hematoma expansion, and patient preferences should also be considered.
Score 0 — Low Risk — 0–0
30-day mortality: 0%. Excellent prognosis.
Management: Standard monitoring in stroke unit or ward. Blood pressure management per guidelines. Early rehabilitation assessment.
Score 1 — Moderate Risk — 1–1
30-day mortality: 13%. Favorable prognosis overall.
Management: ICU or step-down monitoring. Neurological checks every 1-2 hours. Repeat CT at 6 hours.
Score 2 — Moderate-High Risk — 2–2
30-day mortality: 26%. One in four patients may not survive.
Management: ICU admission. Consider neurosurgical consultation. Control hypertension, reverse anticoagulation.
Score 3 — High Risk — 3–3
30-day mortality: 72%. High likelihood of poor outcome.
Management: ICU admission with aggressive medical management. Neurosurgical consultation for possible surgical evacuation. Discuss goals of care.
Score 4-6 — Very High Risk — 4–6
30-day mortality: 97-100%. Very poor prognosis.
Management: Discuss goals of care with family. Consider palliative consultation. Aggressive medical management including ICP monitoring if appropriate.
Reference Ranges
| Population | Normal Range | Notes |
|---|---|---|
| Patients with spontaneous ICH (non-traumatic) | 0-6 points | Higher score = higher mortality. 0: 0%, 1: 13%, 2: 26%, 3: 72%, 4: 97%, 5-6: 100% |
Dr. Mahmoud El-Sayed, MD, Neurology Specialist
Dr. Mahmoud El-Sayed is a neurology consultant with expertise in cerebrovascular disease and neurocritical care.
View medical review board & editorial policy →Example Calculation
A 75-year-old male with history of hypertension on warfarin for atrial fibrillation presents with acute onset right-sided weakness and aphasia. His blood pressure is 185/105 mmHg. GCS on arrival is 10 (E3 V3 M4). CT head without contrast shows a left putaminal hemorrhage measuring 5.0 × 4.5 × 3.5 cm. The estimated ICH volume by ABC/2 method is (5 × 4.5 × 3.5)/2 = 39.4 mL. There is no intraventricular extension. The hemorrhage is supratentorial. Age is <80 years. ICH Score: GCS 5-12 = 1 point, Age <80 = 0, Supratentorial = 0, Volume ≥30 mL = 1, No IVH = 0. Total ICH Score = 2/6. Predicted 30-day mortality: 26%. The patient is admitted to the neurological ICU. Warfarin is reversed with vitamin K and 4-factor PCC. His BP is controlled with IV nicardipine. After discussion with neurosurgery, the decision is made for medical management given the deep location and absence of significant mass effect. A goals-of-care discussion is initiated with the family.
Related Conditions
Related Medications
Common Mistakes
Using ICH Score for traumatic ICH (contusions)
The ICH Score was derived and validated only for spontaneous (non-traumatic) intracerebral hemorrhage. For traumatic brain injury with contusions, use the Marshall CT classification or Rotterdam CT score.
Not accounting for IVH when present on CT
IVH may be subtle on CT, especially layering in the occipital horns of the lateral ventricles. Carefully evaluate all ventricular spaces on the CT scan. The presence of IVH increases mortality risk and scores 1 point.
Using ICH Score for withdrawal of care decisions in isolation
The ICH Score provides population-level mortality estimates, not individual predictions. Many patients with scores of 3-4 survive with acceptable functional outcomes. Scores should be used as one component of a comprehensive assessment including patient wishes, clinical trajectory, and family input.
Frequently Asked Questions
What is the ICH Score and who developed it?
How is ICH volume calculated on CT?
Can the ICH Score be used for surgical decision-making?
References
- Hemphill JC, Bonovich DC, Besmertis L, et al. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32(4):891-897. PubMed
- Hemphill JC, Greenberg SM, Anderson CS, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(7):2032-2060. PubMed
- Clarke JL, Johnston SC, Farrant M, et al. External validation of the ICH score. Neurocrit Care. 2004;1(1):53-60. PubMed