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
  • a tool to guide the decision to start anticoagulation in AF patients
  • always compare the risk for major bleeding (calculated by the HAS-BLED score) to the risk for thromboembolic events (calculated by the CHA2DS2-VASc score) ⇒  does the benefit of anticoagulation outweighs 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 let 1
Drugs / alcohol
medication usage predisposing 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 %
There is not enough data for higher scores, risk is very likely over 10%

A score ≥ 3 is associated with a higher risk of major bleeding. Frequent controls, DOAC usage, or alternatives to anticoagulation are advisable.

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-stroke score

ABC-stroke score

ABC-bleeding score

ABC-bleeding score
ORBIT
  • ORBIT bleeding risk score has a better ability to predict major bleeding in AF patients when compared with HAS-BLED and ATRIA risk scores. The ORBIT risk score can provide a simple, easily remembered tool to support clinical decision making   [O´Brian,  2015]  [Hilkens, 2017]
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 allocates 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
Spetzler-Martin grade 3
HEMORR2HAGES
  • 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 Afib patients’ major bleeding risk
    • 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
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
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