What the sICH score measures
Nontraumatic intracerebral hemorrhage (ICH) is most often attributed to small-vessel disease (typically hypertension-related) or cerebral amyloid angiopathy in older adults. A minority of cases arise from treatable vascular structural lesions such as arteriovenous malformations, ruptured saccular aneurysms with purely intraparenchymal hemorrhage, dural venous sinus thrombosis with venous infarction and hemorrhage, and related conditions. Missing these diagnoses can delay definitive therapy, misattribute mechanism, and affect secondary prevention and family counseling.
The Secondary Intracerebral Hemorrhage (sICH) score was developed to stratify the pre-test probability that a given spontaneous ICH is “secondary” in the sense of an underlying macrovascular or major venous abnormality detectable on neurovascular imaging. It combines readily available emergency department data with a structured reading of the noncontrast head CT (NCCT). The score does not predict short-term mortality, functional outcome, or hematoma expansion; it is strictly an etiology triage tool aligned with decisions about CT angiography, MR angiography, venous imaging, or whether to proceed to catheter angiography when noninvasive tests are negative or equivocal.
When the score is intended to be used
Apply the sICH score in adults with acute spontaneous ICH confirmed on NCCT when you are deciding how aggressively to pursue vascular imaging. It is most informative in settings where not every ICH automatically receives immediate CT angiography, or when initial noninvasive vascular imaging is negative and you must judge whether invasive angiography remains justified. The original derivation and validation cohorts consisted of patients who underwent multidetector CT angiography as part of their workup; the score therefore reflects populations where advanced vascular imaging was clinically pursued.
The score should not be applied when the presentation clearly falls outside the study scope, including isolated subarachnoid hemorrhage limited to the basal cisterns (aneurysmal SAH pathway), hemorrhagic transformation within a well-defined acute territorial infarct, a known intracranial mass or already-documented vascular malformation, or a presentation that fulfills high-probability cerebral amyloid angiopathy criteria where vascular imaging may be lower yield. It is also not a substitute for formal neuroradiology interpretation of subtle NCCT clues.
How noncontrast CT is categorized
The NCCT component is central because several vascular etiologies leave early parenchymal or venous signatures before contrast is given. The score assigns two points to a “high-probability” NCCT, one point to an “indeterminate” pattern, and zero points to a “low-probability” pattern.
- High-probability NCCT means either enlarged or calcified vessels along the margin of the hematoma, suggesting a nidus or shunt-related anatomy, or hyperattenuation within a dural venous sinus or cortical vein along the plausible venous drainage territory of the hemorrhage, raising concern for cortical venous or sinus thrombosis.
- Low-probability NCCT means the scan does not show those high-probability features and the hemorrhage is located in typical deep hypertensive territories: basal ganglia, thalamus, or brainstem. This pattern is more consistent with small-vessel rupture, though rare exceptions exist.
- Indeterminate NCCT encompasses all other qualifying scans, commonly including many lobar or cerebellar hemorrhages without overt vascular or venous hyperattenuation. This category carries intermediate points because it is the imaging phenotype in which occult vascular lesions are often sought.
Clinical variables in the score
Beyond imaging, the score incorporates features that independently associate with vascular etiology in multivariable models. Age is stratified into three bands: younger adults accumulate more points because vascular malformations and some aneurysmal presentations occur disproportionately at earlier ages, whereas very late-life hemorrhage more often reflects small-vessel or amyloid-related disease. Female sex contributes one point in the published weighting, reflecting the distribution of predictors in the derivation cohort rather than a pathognomonic rule. The final clinical element awards one point when the patient has neither treated or known hypertension nor impaired coagulation at presentation, because hypertension is so tightly linked to primary deep hemorrhage and coagulopathy broadens differential diagnosis toward iatrogenic and hematologic mechanisms.
“Hypertension” in the original definition includes a documented history or use of antihypertensive medications at presentation. “Impaired coagulation” includes therapeutic antiplatelet use with aspirin or clopidogrel, platelet count below conventional thresholds, supratherapeutic INR, or markedly prolonged aPTT as specified in the primary report. If either hypertension or coagulopathy is present, the “neither” criterion fails and that point is not awarded.
Calculating and interpreting the total
Components are summed to a total ranging from 0 to 6. In the combined derivation and validation experience, receiver-operating-characteristic analysis supported a practical threshold near greater than 2 for flagging patients in whom vascular imaging yields are clinically meaningful, with reported sensitivity and specificity in the original CTA-based cohorts that justify using the score as a risk stratifier rather than as a binary rule. Patients with scores of 0–2 accounted for the majority of individuals in the original population and had a low overall rate of angiographically defined vascular etiology, whereas scores of 3 and higher concentrated much of the yield, with the highest score group approaching universal positivity in the original descriptive tables.
A separate angiographic validation series reported increasing crude frequencies of positive studies across integer totals, which clinicians may use as qualitative calibration; exact percentages vary by referral patterns, imaging protocol, and case mix. The key clinical takeaway is monotonic risk: higher scores justify more definitive vascular evaluation and more persistent pursuit when initial tests are unrevealing, always balanced against kidney injury, contrast load, procedural stroke risk, and instability from mass effect.
How this fits emergency and inpatient pathways
Many comprehensive stroke centers now obtain vascular imaging broadly for spontaneous ICH. Where practice is selective, the sICH score can help articulate why a patient with a lobar hemorrhage in a younger, normotensive individual merits immediate CTA, while another presentation with classic deep hypertensive morphology in an older treated hypertensive patient may proceed along a different imaging ladder. After a negative or ambiguous CTA, the score can frame shared decision-making about catheter angiography, venous-phase imaging, or MRI with vessel sequences, particularly when examination instability or anticoagulation complicates transport to the angiography suite.
Neurology, neurosurgery, emergency medicine, and radiology should align on local protocols. The score informs probability, not a mandate: clinical gestalt, institutional resources, and serial examination remain paramount. Any suspicion for vasculitis, venous infarction, or neoplasm may prompt workup even when the numeric total is low.
Limitations to keep in mind
The sICH score reflects cohorts enriched by performance of advanced imaging and may overestimate or underestimate utility in populations with different baseline testing rates. NCCT categorization requires training; inter-reader disagreement on subtle hyperattenuation can shift assigned points. The score does not incorporate MRI markers, magnetic resonance venography, or emerging CT perfusion or radiomic features. Finally, therapeutic decisions—blood pressure targets, reversal agents, surgery, or observation—should never hinge on this etiology probability alone.