Practical scoring system for the identification of patients with intracerebral hemorrhage at highest risk of harboring an underlying vascular etiology: the Secondary Intracerebral Hemorrhage Score

Abstract

Background and purpose: An ICH patient's risk of harboring an underlying vascular etiology varies according to baseline clinical and NCCT characteristics. Our aim was to develop a practical scoring system to stratify patients with ICH according to their risk of harboring a vascular etiology.

Materials and methods: Using a data base of 623 patients with ICH evaluated with MDCTA during a 9-year period, we developed a scoring system based on baseline clinical characteristics (age group [0-2 points], sex [0-1 point], neither known HTN nor impaired coagulation [0-1 point]), and NCCT categorization (0-2 points) to predict the risk of harboring a vascular lesion as the ICH etiology (SICH score). We subsequently applied the SICH score to a prospective cohort of 222 patients with ICH who presented to our emergency department during a 13-month period. Using ROC analysis, we calculated the AUC and MOP for the SICH score in both the retrospective and prospective patient cohorts separately and the entire patient population. Patients with SAH in the basal cisterns were excluded.

Results: A vascular etiology was found in 120 of 845 patients with ICH evaluated with MDCTA (14.2%), most commonly AVMs (45.8%), aneurysms with purely intraparenchymal rupture (21.7%), and DVSTs (16.7%). The MOP was reached at a SICH score of >2, with the highest incidence of vascular ICH etiologies in patients with SICH scores of 3 (18.5%), 4 (39%), 5 (84.2%), and 6 (100%). There was no significant difference in the AUC between both patient cohorts (0.86-0.87).

Conclusions: The SICH score successfully predicts a given ICH patient's risk of harboring an underlying vascular etiology and could be used as a guide to select patients with ICH for neurovascular evaluation to exclude the presence of a vascular abnormality.

Figures

Fig 1.

A 45-year-old woman without a history of hypertension and with intact coagulation presented with acute onset of headache and visual changes. A and B, High-probability NCCT scan demonstrates an acute right occipital ICH with calcifications along its posteroinferior margin (arrowhead, B; SICH score, 6). There was associated subdural hemorrhage overlying the right temporal lobe but no associated IVH or SAH. C, CTA source image demonstrates a tangle of abnormal vessels along the posteroinferior aspect of the ICH (arrowhead) with associated calcifications (arrow), consistent with an AVM. D, CTA MIP image in the axial plane redemonstrates the right occipital AVM (arrowhead) with arterial supply from branches of the right posterior cerebral artery and drainage to the right transverse sinus.

Fig 2.

A 50-year-old woman with a history of hypertension and intact coagulation presented with acute onset of left-sided weakness. A, Indeterminate NCCT scan demonstrates an acute right temporal ICH without associated IVH or SAH (SICH score, 3). B, CTA source image demonstrates an 11-mm outpouching arising from the right MCA bifurcation (arrowhead), consistent with an aneurysm. C, CTA MIP image in the axial plane redemonstrates the right MCA bifurcation aneurysm (arrowhead).

Fig 3.

A 60-year-old woman without a history of hypertension and with intact coagulation presented with increasing headache during the past several days. A and B, High-probability NCCT scan demonstrates an acute right mesiotemporal ICH with subtle associated hyperattenuation within the distal right vein of Labbe (arrow, B) and right transverse sinus (arrowhead, B; SICH score,5). C, Coronal NCCT scan reformation improves depiction of the hyperattenuation within the distal right vein of Labbe (arrow) and right transverse sinus (arrowhead). D, CT venogram source image obtained immediately after the CTA demonstrates nonopacification of the right transverse and sigmoid sinuses (arrowheads), consistent with DVST. E, CT venogram MIP image after calvarial segmentation redemonstrates the right transverse and sigmoid sinus thrombosis (arrowheads).

Fig 4.

A 44-year-old woman without history of hypertension and with intact coagulation presented with headache. A, Indeterminate NCCT scan demonstrates a left parietal ICH (SICH score, 5). There was associated subdural hemorrhage overlying the left frontal lobe but no associated IVH or SAH. B, CTA source image demonstrates an abnormal vessel along the inferior aspect of the ICH in the left parietal lobe, consistent with an AVF (arrowhead). C, Frontal left internal carotid artery catheter angiogram confirms the presence of a left parietal AVF with deep venous drainage into the left internal cerebral vein.

Fig 5.

A 50-year-old woman without a history of hypertension and with intact coagulation presented with acute onset of unresponsiveness. A, Low-probability NCCT scan demonstrates an acute right basal ganglia ICH with associated IVH (SICH score, 3). B, CTA source image demonstrates a 3-mm outpouching arising from a lenticulostriate branch of the right middle cerebral artery (arrowhead), consistent with an aneurysm. C, CTA MIP image in the sagittal plane redemonstrates the right lenticulostriate aneurysm (arrowheads) as well as a diffuse luminal irregularity in the visualized anterior cerebral artery branches (arrows). D, CTA MIP image in the axial plane demonstrates diffuse luminal irregularity in the right middle cerebral artery branches (arrowheads). These findings are consistent with vasculitis with secondary pseudoaneurysm formation and rupture. The patient was ultimately found to have Lyme disease affecting the central nervous system.

Fig 6.

A 42-year-old woman without a history of hypertension and with intact coagulation presented with severe headache. A, Indeterminate NCCT scan demonstrates an acute right temporal ICH without associated IVH or SAH (SICH score, 5). B, CTA source image demonstrates occlusion of the supraclinoid segments of the internal carotid arteries and proximal M1 segments of the middle cerebral arteries bilaterally, with numerous associated lenticulostriate collateral vessels (arrowheads), consistent with Moyamoya phenomenon. C, CTA MIP image in the axial plane redemonstrates the findings of Moyamoya phenomenon (arrowheads).