ADD-ONS / SCALES

Intracerebral hemorrhage scales and scores

Created 26.05.2020, last update 08.06.2022

ICH score

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Max-ICH score

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Spot sign

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HAS-BLED

→ HAS-BLED score calculator

a tool to guide the decision to initiate anticoagulation in patients with Afib
always compare the risk for major bleeding (calculated by the HAS-BLED score) with the risk of thromboembolic events (calculated by the CHA₂DS₂-VASc score) ⇒ does the benefit of anticoagulation outweigh the risk of bleeding?
a study comparing HEMORR2HAGES, ATRIA and HAS-BLED showed superior performance of the HAS-BLED score compared to the other two scores

HAS-BLED score
Hypertension	uncontrolled BP, >160 mmHg SBP	1
Abnormal liver/renal function	renal disease – dialysis, transplant, Cr >2.26 mg/dL or >200 µmol/L liver disease – cirrhosis or bilirubin >2x normal or AST/ALT/AP >3x normal	1 1
Stroke	previous stroke	1
Bleeding	prior major bleeding or predisposition to bleeding	1
Labile INR	unstable INR, time in therapeutic range <60%	1
Elderly	age ≥ 65 years	1
Drugs/alcohol	medication use that predisposes to bleeding – aspirin, clopidogrel, NSAIDs heavy alcohol use	1 1

HAS-BLED score	Pisters et al.annual ICH risk	Lip et al.annual ICH risk
0	1.1%	0.9%
1	1%	3.4%
2	1.9%	4.1%
3	3.7%	5.8%
4	8.7%	8.9%
5	12.5%	9.1 %
Not enough data for higher scores; risk is most likely > 10%

A score ≥ 3 is associated with an increased risk of major bleeding. Frequent monitoring, DOAC use, or alternatives to anticoagulation are recommended.

SMASH-U

*Etiologic Classification of Intracerebral Hemorrhage – SMASH-U* [Meretoja, 2012]
	incidence	mortality at 3 months
Structural lesions (cavernous malformation, AVM)	5%	4 %
Medication (warfarin, DOAC, antiplatelet therapy)	14%	54 %
Cerebral Amyloid Angiopathy (CAA)	20%	22 %
Systemic disease (liver, kidney disease, thrombocytopenia/thrombocytopathies)	5%	44 %
Hypertension	35%	33 %
Undetermined	21%	30%

ABC

in addition to clinical factors, the ABC-bleeding risk score also incorporates the biomarkers: high-sensitivity troponin T, growth differentiation factor–15, and hemoglobin

→ ABC-bleeding score online calculator

→ more about ABC score see here

ABC-stroke score

ABC-bleeding score

ORBIT

ORBIT bleeding risk score has a better ability to predict major bleeding in AFib patients when compared to HAS-BLED and ATRIA risk scores. The ORBIT risk score may provide a simple, easy-to-remember tool to aid in clinical decision making [O´Brian, 2015] [Hilkens, 2017]

→ ORBIT online calculator

Older age ( >75 y)	1
Reduced hemoglobin/Hct/anemia (men <13 g/dL and Hct < 40%, women < 12 g/dL and Hct < 36% )	2
Bleeding	2
Insufficient kidney function (GFR < 60 mL/min/1.73 m²)	1
Treatment with antiplatelets	1

Maximum score	7
score 0–2 – low risk ~ 2.4% / y score 3 – medium risk ~ 4.7% / y score ≥ 4 – high risk ~ 8.1% / y

Spetzler-Martin

The Spetzler-Martin arteriovenous malformation (AVM) grading system assigns points for various angiographic features to predict the morbidity/mortality risk of surgery

Spetzler-Martin AVM grading scale (grade I-V)
	score
Nidus size – largest nidus diameter on angiography small (< 3 cm) medium (3-6 cm) large (> 6 cm)	1 2 3
The eloquence of the adjacent brain non-eloquent eloquent sensory, motor, language, or visual cortex internal capsule hypothalamus / thalamus cerebellar peduncles (superior, middle, or inferior) and cerebellar nuclei brainstem	0 1
Venous drainage → anatomy of veins and sinuses superficial veins deep cerebral veins	0 1

HEMORR2HAGES

→ HEMORR₂HAGES calculator

HEMORR₂HAGES score is used to stratify patients’ risk of bleeding after anticoagulation for atrial fibrillation (Afib) in conjunction with situation-specific risks
a systemic review comparing the performance of HAS-BLED, ATRIA, and HEMORR₂HAGES recommended HAS-BLED for the assessment of major bleeding risk in Afib patients
- HEMORR₂HAGES had a higher diagnostic accuracy but was considered more difficult to use due to its complexity

Hepatic/renal disease	1
Ethanol abuse	1
Malignancy history	1
Older (age >75 y)	1
Reduced platelet count or function, including aspirin therapy	1
Re-bleeding risk (history of prior bleeding)	2
Hypertension (uncontrolled)	1
Anemia (Hgb <13 g/dL for Men; Hgb <12 g/dL for Women)	1
Genetic factors (CYP 2C9 single-nucleotide polymorphisms)	1
Excessive fall risk	1
Stroke history	1
Total points	12

The annual risk of bleeding

Score 0 ~ 1.9 %/y

Score 1 ~ 2.5 %/y

Score 2 ~ 5.3 %/y

Score 3 ~ 8.4 %/y

Score 4 ~ 10.4 %/y

Score ≥ 5 ~ 12.3 %/y