The BRAIN score predicts significant expansion (> 33% or 6cc growth) within 24 hours of ictus, identifying high-risk hemorrhagic stroke patients.
Neurological Heuristic Probe
Input the baseline ICH characteristics and anticoagulation status to quantify the risk of acute hematoma expansion within the 24-hour window.
Guidelines & Evidence
Clinical Details
Section 1
When to Use
When to Use
Acute spontaneous intracerebral haemorrhage (ICH) within 6 hours of onset.
Predicting early haematoma expansion (defined as >33% or 6 cm³ increase).
Identifying candidates for intensive blood pressure lowering (e.g., INTERACT2/ATTACH-II goals).
Useful when CTA "spot sign" imaging is unavailable.
Section 2
Formula & Logic
Scoring Matrix
Variable
Scoring
Baseline volume (cm³)
< 10 (0), 10–20 (3), 20–30 (5), > 30 (8)
Recurrence (prior ICH)
No (0), Yes (4)
Anticoagulation use
No (0), Yes (6)
Intraventricular extension (IVH)
No (0), Yes (3)
Number of bleeding sites
Single (0), Multiple (3)
Total Score Range
0–24. Higher scores indicate a significantly higher risk of expansion.
Section 3
Pearls/Pitfalls
The Anticoagulation Penalty
The BRAIN score applies a heavy +6 penalty for anticoagulation, acknowledging that the "onlooker effect" of impaired coagulation is the single most modifiable driver of expansion. Immediate reversal is mandatory for high BRAIN scores.
Section 4
Evidence Appraisal
Primary Reference
BRAIN score to predict early hematoma expansion in spontaneous intracerebral hemorrhage
Wang X et al. • JAMA Neurol. 2015;72(10):1176-1181
Developed by researchers at the George Institute for Global Health (Australia) as a simple bedside tool for identifying high-risk ICH patients requiring intensive blood pressure management and possible reversal strategies.
