ICH Score
Intracerebral Hemorrhage Prognosis
Mortality prediction reflects Hemphill et al. (2001) validation.
Clinical Intelligence
Select patient metrics to execute high-fidelity mortality prediction based on the Original Hemphill ICH Score.
Ready For Calculation
Guidelines & Evidence
Verified
Last Review: 2026
When to Use
Primary Indications
Predicting 30-day mortality in patients with spontaneous (non-traumatic) intracerebral hemorrhage – the most widely validated prognostic scale for ICH
Risk stratification on presentation – guides intensity of monitoring (ICU vs ward), family discussions about prognosis, and decisions regarding withdrawal of care
Standardizing clinical research – used as entry criterion, stratification variable, and outcome adjustment in ICH trials (e.g., CLEAR III, MISTIE III, FAST trials)
Quality benchmarking – comparing observed vs expected mortality across stroke centers (risk-adjusted outcomes)
Early communication with families – provides a data-driven estimate of survival probability, though MUST be accompanied by caveats (see clinical edge)
Guiding transfer decisions – patients with ICH score ≥3 have high mortality (≥40-50%) and may warrant transfer to tertiary centers with neurosurgery and intensive care
Contraindications / Limitations
DO NOT use for traumatic ICH (e.g., hemorrhagic contusions, epidural/subdural hematoma) – derived and validated only for spontaneous, non-traumatic ICH
DO NOT use for hemorrhagic conversion of ischemic stroke – different pathophysiology (reperfusion injury, not primary vessel rupture)
DO NOT use to justify early withdrawal of care – high scores (4-5) have high mortality, but AHA/ASA guidelines recommend aggressive full care for at least the first 24 hours to avoid self-fulfilling prophecy
Limited utility in low-resource settings without CT – requires CT for ICH volume, location, and intraventricular hemorrhage assessment
Poor discrimination at extremes – Score 0 (17-23% mortality in some studies, not 0% across all populations), Score 5 (variable mortality depending on withdrawal of care practices)
Does NOT predict functional outcome – only 30-day mortality. A surviving patient with high ICH score may have severe disability (modified Rankin Scale 4-5)
Does NOT account for hematoma expansion – the "spot sign" on CTA predicts expansion and may worsen prognosis beyond baseline score
Performance Metrics (30-Day Mortality)
| ICH Score | Original Cohort (Hemphill 2001, n=152) | Uganda Cohort (Abdallah 2018, n=73) | Interpretation |
|---|---|---|---|
| 0 | 0% (0/26) | 17% (2/12) | Low risk – excellent prognosis in high-income settings; higher mortality (17%) in Uganda suggests limited ICU access affects even "good prognosis" patients |
| 1 | 13% (5/38) | 23% (3/13) | Low-intermediate risk – mortality increases modestly |
| 2 | 26% (11/42) | 47% (8/17) | Intermediate risk – significant mortality (26-47%); ICU monitoring recommended |
| 3 | 72% (13/18) | 48% (11/23) | High risk – Uganda cohort had lower mortality (48% vs 72%) possibly due to younger age (mean 60 vs 70+), HIV+ status, or different withdrawal practices |
| 4 | 97% (1/1) | 100% (6/6) | Very high risk – near-uniform mortality in both studies irrespective of setting |
| 5 | 100% (6/6) | 100% (2/2) | Extremely high risk – universal mortality at 30 days |
| 6 | (Not present in original) | (Not present) | Theoretical max score (GCS 3-4=2pts + age≥80=1 + infratentorial=1 + volume≥30=1 + IVH=1 = 6) but rarely seen |
Additional Predictors Identified in Uganda Validation Study
In the 2018 Uganda validation study (n=73, mean age 60, 45% female, 14% HIV-positive), two additional factors independently predicted 30-day mortality beyond the standard ICH score:
Female sex – adjusted relative risk (aRR) 2.17 (95% CI 1.32-3.59). Women had higher case fatality at lower ICH scores compared to men. Mechanism unclear; prior studies have shown conflicting results (some show higher mortality in men, others no difference).
HIV infection – aRR 1.92 (95% CI 1.07-3.43). HIV has been previously associated with poor stroke outcomes in sub-Saharan Africa, particularly with advanced disease and immunosuppression.
Clinical implication: In settings with high HIV prevalence and/or where sex differences are observed, the ICH score may moderately underperform. The addition of 1 point for female sex and 1 point for HIV seropositivity improved the AUC from 0.73 to 0.81 (modest improvement). Further validation needed before modifying the standard score.
Related Scores in Practice
In clinical practice, this assessment is frequently evaluated alongside other validated measures. Depending on the patient's presentation and specific diagnostic requirements, you may also need to utilize the NIH Stroke Scale, Glasgow Coma Scale (GCS), Modified Ranklin Scale or the Hunt Hess Sah to formulate a comprehensive care plan.
Last Comprehensive Review: 2026