ICH Score Calculator: Intracerebral Hemorrhage 30-Day Mortality
The ICH Score is a validated 5-component grading scale that estimates 30-day mortality after spontaneous intracerebral hemorrhage. Enter the Glasgow Coma Scale, hematoma volume, presence of intraventricular hemorrhage, lesion origin, and patient age to get an instant score (0-6) with its associated mortality rate and a full breakdown of how each factor contributes.
What is the ICH Score?
The ICH Score is a simple, validated grading scale developed by Hemphill and colleagues in 2001 to provide rapid bedside prognosis in patients with spontaneous intracerebral hemorrhage. It uses five readily available clinical and radiographic variables: Glasgow Coma Scale at presentation, hematoma volume on CT, presence of intraventricular hemorrhage, infratentorial or supratentorial location, and patient age. The total score ranges from 0 to 6 and correlates directly with 30-day mortality: a score of 0 carries near-zero mortality while scores of 5-6 are associated with mortality approaching 100%.
How the score is calculated
Each component contributes a fixed number of points. The Glasgow Coma Scale contributes the most: 2 points for a GCS of 3-4, 1 point for GCS 5-12, and 0 points for GCS 13-15, reflecting the strong correlation between level of consciousness and outcome. A hematoma volume of 30 mL or greater adds 1 point, as larger bleeds cause more mass effect and edema. Intraventricular extension of blood (IVH) adds 1 point, partly because IVH obstructs CSF flow and worsens intracranial pressure. An infratentorial origin (brainstem or cerebellum) adds 1 point because even small bleeds in the posterior fossa can compress critical structures. Finally, age 80 or above adds 1 point, reflecting reduced physiological reserve. The ICH Score = GCS component + volume component + IVH component + origin component + age component.
Clinical use and limitations
The ICH Score was designed as a communication and prognostication tool, not as a guide to withhold or withdraw care. Studies have consistently validated its discrimination across multiple populations, with area-under-curve values typically in the 0.80-0.90 range for 30-day mortality. However, it does not account for anticoagulant use, hematoma expansion, timing of treatment, or aggressive intervention. The score is most useful for rapid risk stratification on arrival, guiding triage decisions, informing family conversations, and comparing patients across research cohorts. It should always be interpreted alongside the full clinical picture by the treating team.
Hematoma volume and the ABC/2 method
Hematoma volume is one of the most modifiable prognostic factors because early surgical evaluation or hemostatic treatment may limit expansion. Volume is typically estimated from CT imaging using the ABC/2 formula: A is the largest diameter of the hematoma, B is the diameter perpendicular to A on the same slice, and C is the number of CT slices with hematoma multiplied by the slice thickness in centimetres. Dividing the product of A, B, and C by 2 gives an approximation of the ellipsoid hematoma volume in milliliters. The 30 mL threshold in the ICH Score was derived empirically from the original cohort and remains the most widely used cut-off.
ICH Score - 30-day mortality by total score
| ICH Score | GCS range | 30-day mortality | Interpretation |
|---|---|---|---|
| 0 | 13-15 | 0% | Minimal risk |
| 1 | 5-15 (no other factors) | 13% | Low risk |
| 2 | Variable | 26% | Moderate risk |
| 3 | Variable | 72% | High risk |
| 4 | Variable | 94% | Very high risk |
| 5 | 3-4 (all factors present) | 100% | Extremely high risk |
| 6 | Maximum severity | 100%* | Extremely high risk |
Mortality rates from the original Hemphill 2001 derivation cohort (n = 152 patients). Validated in subsequent multi-centre studies.
Frequently asked questions
What does an ICH Score of 3 mean?
An ICH Score of 3 was associated with approximately 72% 30-day mortality in the original Hemphill 2001 derivation study. It represents a high-risk presentation requiring intensive monitoring and early multidisciplinary team involvement. The exact mortality in any individual patient will depend on additional factors such as hematoma expansion, response to treatment, and comorbidities.
What GCS range counts for 2 points in the ICH Score?
A Glasgow Coma Scale of 3 or 4 scores 2 points, the maximum for any single component of the ICH Score. GCS 5-12 scores 1 point, and GCS 13-15 scores 0 points. The GCS component has the largest potential contribution to the total, reflecting the dominant role of level of consciousness in predicting ICH outcome.
Does the ICH Score apply to all types of intracranial hemorrhage?
The ICH Score was developed specifically for spontaneous (non-traumatic) intracerebral hemorrhage. It was not validated for traumatic brain injury, subdural hematoma, epidural hematoma, or subarachnoid hemorrhage, which have different pathophysiology and prognosis. For subarachnoid hemorrhage, the Hunt and Hess Scale or WFNS grading scale are more appropriate.
Is the ICH Score used to decide whether to treat a patient?
No. The ICH Score is explicitly a prognostic and communication tool, not a treatment decision rule. Clinical decisions about surgical intervention, aggressive medical management, or goals-of-care discussions must incorporate many factors beyond the score, including patient and family wishes, the treating team's judgment, institutional protocols, and the trajectory of the clinical course.
How accurate is the ICH Score?
In the original Hemphill 2001 paper, the score had a c-statistic (area under the ROC curve) of 0.97 for 30-day mortality in the derivation cohort. Independent validation studies have generally found c-statistics in the 0.80-0.92 range, confirming good but not perfect discrimination. Calibration (how well predicted rates match observed rates) can vary across populations, particularly in settings with different treatment intensities.
What is the maximum possible ICH Score?
The maximum ICH Score is 6, which would require: GCS 3-4 (2 points), hematoma volume 30 mL or more (1 point), intraventricular hemorrhage present (1 point), infratentorial origin (1 point), and age 80 or older (1 point). A score of 6 was associated with 100% mortality in the original study, though no patients in that initial cohort actually achieved a score of 6, making the estimate an extrapolation.