Intracerebral hemorrhage: update and future directions

Eva ROCHA

Universidade Federal de São Paulo, Hospital São Paulo, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil.

Carolina ROUANET

Universidade Federal de São Paulo, Hospital São Paulo, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil.

Danyelle REGES

Universidade Federal de São Paulo, Hospital São Paulo, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil.

Vivian GAGLIARDI

Universidade Federal de São Paulo, Hospital São Paulo, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil.

Aneesh Bhim SINGHAL

Massachusetts General Hospital, Stroke Service, Department of Neurology, Boston MA, USA.

Gisele Sampaio SILVA

Universidade Federal de São Paulo, Hospital São Paulo, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil.

Hospital Israelita Albert Einstein, Academic Research Organization, São Paulo SP, Brazil.

Conflict of interests: Gisele Silva is the main investigator in the ETHICS study.

Authors’ contributions: Dr. Eva Rocha conceptualized and drafted the manuscript; Dr. Carolina Rouanet drafted the manuscript; Dr. Danyelle Reges drafted the manuscript; Dr. Vivian Gagliardi drafted the manuscript; Dr. Aneesh Bhim Singhal revised the manuscript for intelectual content; Dr. Gisele Sampaio Silva conceptualized and revised the manuscript for intellectual content.

Modified Boston criteria
Definite CAA	Full postmortem examination demonstrating: • Lobar, cortical or cortical-subcortical hemorrhage • Severe CAA with vasculopathy • Absence of other diagnostic lesion
Probable CAA with supporting pathology	Clinical data and pathological tissue (evacuated hematoma or cortical biopsy) demonstrating: • Lobar, cortical or cortical-subcortical hemorrhage (including ICH, CMB or cSS) • Some degree of CAA in specimen • Absence of other diagnostic lesion
Probable CAA	Clinical data and MRI or CT demonstrating: • Multiple hemorrhages (ICH, CMB) restricted to lobar, cortical or cortical-subcortical regions (cerebellar hemorrhage allowed) or single lobar, cortical or cortical-subcortical hemorrhage and cSS (focal or disseminated) • Age ≥55 years • Absence of other cause of hemorrhage*
Possible CAA	Clinical data and MRI or CT demonstrating: • Single lobar, cortical or cortical-subcortical ICH, CMB, or cSS (focal or disseminated) • Age ≥55 years • Absence of other cause of hemorrhage*

Etiologic classification SMASH-U
S - Structural lesion	Image or pathology confirming structural vascular malformation diagnosed on the site of ICH
M - Medication	Warfarin use with INR greater than or equal to 2, direct oral anticoagulants within 3 days, therapeutic IV heparin, or systemic thrombolysis
A - Amyloid angiopathy	Lobar, cortical or subcortical hemorrhage and age ≥55 years
S - Systemic disease/other	Systemic disease or other ICH etiology except from anticoagulation, hypertension or amyloid angiopathy
H - Hypertension	Deep or infratentorial hemorrhage or pre-ICH hypertension, defined as: a) Most recent pre-ICH blood pressure ≥160×100 mmHg b) Mention of elevated blood pressure prior to ICH by patient, relative or medical records, with left ventricular hypertrophy as a biomarker of hypertension c) Any use of blood pressure medication prior to ICH
U - Undetermined	None of the above

“BRAIN” score
B- Baseline ICH volume	Milliliters per score: ≤10=0 10-20=5 >20=7
R- Recurrent ICH	Yes=4
A - Anticoagulation with warfarin at onset	Yes=6
I - Intraventricular extension	No=0 Yes=2
N - Number of hours to baseline computed tomography	≤1=5; 1-2=4; 2-3=3; 3-4=2; 4-5=1; >5=0
Total	Number of points and risk of expansion: 0-5: 3.4-7.7% 6-10: 11.3-23.1% 11-15: 27.2-46.7% 16-20: 52.1-71.9% 20-24: 76.0-85.8%

ICH scale and prognosis
Glasgow Coma Scale	3-4 5-12 13-15	2 1 0
Hematoma volume	≥30 mL <30 mL	1 0
Intraventricular hemorrhage	Yes No	1 0
Infratentorial origin	Yes No	1 0
Age	≥80 years <80 years	1 0
Total	0 1 2 3 4 5 and 6	30-day mortality: 0% 30-day mortality: 13% 30-day mortality: 26% 30-day mortality: 72% 30-day mortality: 97% 30-day mortality: 100%

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