Diagnostic and Severity Assessment in Intracerebral Hemorrhage
Learning Objective
Apply diagnostic and classification criteria to assess intracerebral hemorrhage (ICH) severity and guide immediate management.
1. Importance of Early Severity Assessment
Early recognition and stratification of ICH severity are critical steps that dictate triage decisions, the urgency of anticoagulation reversal strategies, and the potential need for neurosurgical intervention. The initial clinical and radiological findings are powerful predictors of outcome.
- Initial hematoma volume, its specific location, and the patient’s level of consciousness are the strongest predictors of clinical outcome and the risk of hematoma expansion.
- Time is critical. The interval from patient arrival to completion of imaging and essential laboratory results should be minimized, with a target of less than one hour.
- This rapid initial assessment directly informs crucial management decisions, including appropriate blood pressure targets, the urgency of anticoagulation reversal, and the level of care required (e.g., ICU admission).
Key Points
- Hematoma expansion, a major cause of neurological deterioration, occurs in approximately 30% of patients within the first 3–6 hours. This underscores the necessity for rapid assessment.
- Failure to quickly identify high-risk patients (undertriage) can lead to critical delays in life-saving interventions such as hematoma evacuation or placement of an external ventricular drain (EVD).
2. Neuroimaging Interpretation
Non-contrast CT is the cornerstone for confirming an ICH diagnosis. CT angiography provides additional prognostic information and helps identify underlying vascular causes.
A. Non-Contrast CT (NCCT)
The NCCT is the first-line imaging modality due to its speed and high sensitivity for acute blood, which appears as a hyperdense (bright) region within the brain parenchyma.
- Anatomic Classification: Hematomas are classified by location, which has etiological and prognostic implications: lobar (cortex/subcortex), deep (basal ganglia/thalami), cerebellar, or brainstem.
- Volume Estimation (ABC/2 Method): A simple and widely used bedside formula to estimate hematoma volume:
- A = Greatest diameter of the hematoma on a single axial slice (in cm).
- B = Diameter perpendicular to A on the same slice (in cm).
- C = Number of CT slices on which the hematoma is visible, multiplied by the slice thickness (in cm).
- Volume ≈ (A × B × C) / 2
- Intraventricular Hemorrhage (IVH): The presence and extent of blood in the ventricles are quantified using the modified Graeb score (0–12). A higher score indicates more severe IVH and is a key factor in deciding whether to place an external ventricular drain to manage hydrocephalus.
Clinical Pearl: When to Repeat Imaging
Obtain a repeat NCCT within 24 hours if there is a significant clinical change, such as a drop in the Glasgow Coma Scale (GCS) score by ≥2 points or the development of new focal neurological signs. This helps to promptly identify hematoma expansion or developing hydrocephalus.
B. CT Angiography (CTA)
CTA involves the injection of intravenous contrast to visualize the cerebral vasculature and can identify markers of ongoing bleeding or underlying structural lesions.
- Spot Sign: This refers to a focal area of contrast enhancement (pooling) within the hematoma, indicating active bleeding. It is a strong predictor of subsequent hematoma expansion, though its absence does not rule out the risk.
- Sensitivity: ~55%
- Specificity: ~85% for predicting hematoma expansion.
- Lesion Detection: CTA is crucial for identifying underlying causes, especially in younger patients or those with atypical hemorrhage locations. It can detect arteriovenous malformations (AVMs), aneurysms, moyamoya disease, and vascular tumors.
Controversy: Role of Spot Sign–Guided Therapy
While the spot sign is a powerful prognostic marker, the optimal therapeutic strategy based on its presence is still under investigation. Clinical trials are exploring whether more aggressive hemostatic therapies or intensive blood pressure lowering in spot sign-positive patients can improve outcomes. Currently, its presence should prompt heightened vigilance and consideration for more aggressive management, but specific targeted therapies are not yet standard of care.
3. Clinical Scoring Systems
Standardized scoring systems like the Glasgow Coma Scale (GCS) and the ICH Score provide reproducible methods for stratifying severity and predicting patient outcomes.
A. Glasgow Coma Scale (GCS)
The GCS is a fundamental tool for assessing a patient’s level of consciousness. It is scored from 3 (deep coma) to 15 (fully awake).
- Components: Eye Opening (1–4), Verbal Response (1–5), Motor Response (1–6).
- Application: Use the best, unconfounded score. If a component cannot be assessed (e.g., due to intubation), this should be documented with a modifier (e.g., GCS 10T).
- Monitoring: Serial GCS assessments, often hourly for the first 24–72 hours, are essential for detecting neurological deterioration in high-risk patients.
Pitfall: Confounding Factors in GCS Assessment
The GCS score can be artificially lowered by factors such as sedating medications, endotracheal intubation (preventing verbal response), aphasia, or language barriers. It is crucial to document these limitations to avoid misinterpreting the patient’s true neurological state.
B. ICH Score
The ICH Score is a simple, validated tool that uses five clinical and radiological variables to predict 30-day mortality.
| Variable | Points |
|---|---|
| GCS Score 3–4 | 2 |
| GCS Score 5–12 | 1 |
| GCS Score 13–15 | 0 |
| Age ≥80 years | 1 |
| Hematoma Volume ≥30 mL | 1 |
| Intraventricular Hemorrhage | 1 |
| Infratentorial Origin (Brainstem/Cerebellum) | 1 |
| Total Score (0–6) | Predicted 30-Day Mortality |
| 0 | ~0% |
| 1 | ~13% |
| 2 | ~26% |
| ≥3 | ≥72% |
Key Points
- The ICH score should be calculated within the first 24 hours. It is a valuable prognostic tool but should always be used in conjunction with clinical judgment and patient/family goals of care, not as the sole basis for decisions regarding withdrawal of life-sustaining therapy.
4. Laboratory Evaluation
Rapid assessment of coagulation status is essential to identify underlying coagulopathy, guide reversal strategies, and mitigate the risk of further bleeding.
- Standard Assays: Prothrombin time/International Normalized Ratio (PT/INR) for warfarin effect, activated partial thromboplastin time (aPTT) for heparin, fibrinogen levels, and a complete blood count for platelet count.
- DOAC Assays: For patients on direct oral anticoagulants, specific assays are required. An anti-Xa level is used for factor Xa inhibitors (e.g., rivaroxaban, apixaban), while a dilute thrombin time (dTT) or ecarin clotting time (ECT) is used for dabigatran.
- Turnaround Time: The time to result for these assays can be 30–90 minutes. Point-of-care (POC) testing for INR/aPTT can significantly shorten these delays in the emergency setting.
Reversal Agents
| Agent | Indication | Dose | Monitoring |
|---|---|---|---|
| 4-Factor PCC | VKA-associated ICH (INR ≥2) | 25–50 IU/kg IV ×1 | Repeat INR post-infusion |
| Idarucizumab | Dabigatran-associated ICH | 5 g IV (as two 2.5 g infusions) | dTT or aPTT |
| Andexanet alfa | Factor Xa inhibitor–associated ICH | Bolus + infusion per label | Anti-Xa levels (if available) |
Clinical Pearl: Post-Reversal Monitoring
Always check the INR approximately 30-60 minutes after administering 4-factor prothrombin complex concentrate (PCC) to ensure adequate reversal. While effective, reversal agents carry a real, albeit low (<5%), risk of thrombosis, requiring careful patient monitoring.
5. Indications for Advanced Imaging
While CT/CTA is sufficient for most patients, advanced imaging modalities like DSA and MRI are reserved for cases where an underlying vascular lesion is strongly suspected but not identified on initial scans.
- Digital Subtraction Angiography (DSA): This is the gold standard for diagnosing AVMs and aneurysms. It is an invasive procedure that involves catheterization of the cerebral arteries and carries a small (0.5–1%) risk of iatrogenic stroke.
- CTA vs. DSA vs. MRA:
- CTA: The first-line noninvasive vascular assessment.
- MRA (Magnetic Resonance Angiography): A useful alternative to CTA in patients with a severe contrast allergy or renal failure.
- DSA: Used as a follow-up test when noninvasive imaging is negative but clinical suspicion for a vascular lesion remains high (e.g., young patient, lobar hemorrhage).
- MRI: Susceptibility-weighted imaging (SWI) or gradient-recalled echo (GRE) sequences on MRI are highly sensitive for detecting cerebral microbleeds, evidence of chronic hemorrhage, and markers of cerebral amyloid angiopathy.
6. Integrated Diagnostic Workflow
An algorithmic approach that combines imaging, clinical scoring, and laboratory evaluation optimizes decision-making, ensures timely interventions, and promotes efficient use of resources.
7. Case-Based Application
These brief vignettes illustrate the real-time application of imaging, scoring, and laboratory results in guiding management.
Case 1: Deep Basal Ganglia Hemorrhage
- Presentation: 68-year-old male with known hypertension presents with sudden-onset left hemiplegia. GCS is 7 (E1 V2 M4).
- NCCT: Shows a 35 mL right basal ganglia hemorrhage with extension into the ventricles (IVH).
- Labs: INR 1.1, platelets 250,000/μL.
- ICH Score: 4 (GCS=2, Age=0, Volume=1, IVH=1, Origin=0). High predicted mortality.
- CTA: No spot sign or underlying vascular malformation identified.
- Management Plan:
- Admission to the Neuro-ICU for close monitoring.
- Aggressive blood pressure control to a target SBP of 130–140 mmHg.
- Placement of an external ventricular drain (EVD) by neurosurgery to manage hydrocephalus and monitor intracranial pressure.
- Serial NCCT at 6 hours and as clinically indicated to monitor for expansion.
Case 2: Lobar Hemorrhage on a Factor Xa Inhibitor
- Presentation: 78-year-old female on apixaban for atrial fibrillation presents with acute aphasia. GCS is 14 (E4 V4 M6).
- NCCT: Shows a 28 mL right temporal (lobar) hemorrhage without IVH.
- CTA: Positive spot sign is identified within the hematoma.
- Labs: Anti-Xa level is elevated, confirming therapeutic effect of apixaban.
- ICH Score: 2 (GCS=0, Age=0, Volume=0, IVH=0, Origin=0). Moderate predicted mortality.
- Management Plan:
- Immediate administration of andexanet alfa per institutional protocol for reversal.
- Intensive blood pressure lowering to a target SBP <140 mmHg.
- Repeat CTA in 6 hours to assess for hematoma expansion, given the positive spot sign.
- Neurosurgical consultation for potential future evacuation if she deteriorates.
References
- Hemphill JC 3rd, Greenberg SM, Anderson CS, et al. Guidelines for the Management of Patients With Spontaneous Intracerebral Hemorrhage. Stroke. 2015;46(7):2032–2060.
- Greenberg SM, Ziai WC, Cordonnier C, et al. 2022 Guideline for the Management of Spontaneous ICH. Stroke. 2022;53(7):e282–e361.
- Meyer BC, Raman R, Hemmen TM, et al. Care of the Patient With Acute Stroke: Nursing Update. Stroke. 2021;52(3):e164–e178.
- Thompson BG, Brown RD Jr, Amin-Hanjani S, et al. Guidelines for the Management of Unruptured Intracranial Aneurysms. Stroke. 2015;46(8):2368–2400.
- Cook AM, Jones GM, Hawryluk GWJ, et al. Guidelines for the Acute Treatment of Cerebral Edema. Neurocrit Care. 2020;32(3):647–666.
