Research Article| Volume 32, ISSUE 3, 106975, March 2023

Using the ICH score during acute telestroke consults to triage transfer to tertiary centers



      Constrained resources at tertiary centers indicate a need for re-exploration of the practice of routinely transferring all community hospital patients with complex conditions such as hemorrhagic stroke (ICH). We addressed the clinical question of whether information available during acute care telestroke consults could identify ICH patients not requiring specialty services or neurosurgical intervention who could safely remain at the local center for care.


      Retrospective cohort analysis abstracting clinical factors to identify ICH patients associated with need for tertiary care or neurosurgical intervention.


      The Duke Telestroke Network (DTN) in Central NC and Southern Virginia.


      All DTN transferred ICH patients January 1, 2017 to December 31, 2018.


      We defined neurosurgical intervention as craniotomy, digital subtraction angiography, or external ventricular drain placement.

      Measurements and results

      We identified 116 transferred ICH patients. Sixty-two were female, the median Glasgow coma score (GCS) was 13, and the median ICU and hospital length of stay were 2 and 7 days respectively. Thirty of the patients were offered and 27 ultimately received neurosurgical intervention. Using inclusion/exclusion criteria from two ICH surgical trials would have increased the intervention group to 35 patients (30%). Components of the ICH score differentiated surgical from non-surgical patients; patients with an ICH score of <2 and GCS ≥13 received no interventions. Nearly 50% of patients could receive medical management locally.


      Coupling the ICH score and GCS can provide triage guidance identifying patients for retention at the referring center. This retained population is distinct from patients eligible for current or novel surgical interventions. This approach provides a framework for assessment of transfers across specialty areas and furthers the value of telehealth networks.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Stroke and Cerebrovascular Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Institute Of M.
        IOM report: the future of emergency care in the United States health system.
        Acad Emerg Med. 2006; 13: 1081-1085
        • Byrne R.W.
        • Bagan B.T.
        • Slavin K.V.
        • et al.
        Neurosurgical emergency transfers to academic centers in Cook County: a prospective multicenter study.
        Neurosurgery. 2008; 62 (discussion 709-16): 709-716
        • Hemphill 3rd, J.C.
        • Greenberg S.M.
        • Anderson C.S.
        • et al.
        Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American heart association/American stroke association.
        Stroke,. 2015; 46: 2032-2060
        • Holland C.M.
        • McClure E.W.
        • Howard B.M.
        • et al.
        Interhospital transfer of neurosurgical patients to a high-volume tertiary care center: opportunities for improvement.
        Neurosurgery. 2015; 77 (discussion 206-7): 200-206
        • Man S.
        • Zhao X.
        • Uchino K.
        • et al.
        Comparison of acute ischemic stroke care and outcomes between comprehensive stroke centers and primary stroke centers in the United States.
        Circ Cardiovasc Qual Outcomes. 2018; 11e004512
        • Sheth K.N.
        • Smith E.E.
        • Grau-Sepulveda M.V.
        • et al.
        Drip and ship thrombolytic therapy for acute ischemic stroke: use, temporal trends, and outcomes.
        Stroke. 2015; 46: 732-739
        • Kolls B.J.
        • Mace B.E.
        • Dombrowski K.E.
        Implementation of continuous video-electroencephalography at a community hospital enhances care and reduces costs.
        Neurocrit Care. 2018; 28: 229-238
        • Reinhardt U.E.
        The pricing of U.S. hospital services: chaos behind a veil of secrecy.
        Health Aff (Millwood). 2006; 25: 57-69
        • Chen S.
        • Zeng L.
        • Hu Z.
        Progressing haemorrhagic stroke: categories, causes, mechanisms and managements.
        J Neurol. 2014; 261: 2061-2078
        • Virani S.S.
        • Alonso A.
        • Benjamin E.J.
        • et al.
        Heart disease and stroke statistics-2020 update: a report from the American heart association.
        Circulation. 2020; 141: e139-e596
        • Mendelow A.D.
        • Gregson B.A.
        • Rowan E.N.
        • et al.
        Early surgery versus initial conservative treatment in patients with traumatic intracerebral hemorrhage (STITCH[Trauma]): the first randomized trial.
        J Neurotrauma. 2015; 32: 1312-1323
        • Mendelow A.D.
        • Gregson B.A.
        • Rowan E.N.
        • et al.
        Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial.
        Lancet. 2013; 382: 397-408
        • de Havenon A.
        • Joyce E.
        • Yaghi S.
        • et al.
        End-of-treatment intracerebral and ventricular hemorrhage volume predicts outcome: a secondary analysis of MISTIE III.
        Stroke. 2020; 51: 652-654
        • Fiorella D.
        • Arthur A.
        • Bain M.
        • et al.
        Minimally invasive surgery for intracerebral and intraventricular hemorrhage: rationale, review of existing data and emerging technologies.
        Stroke. 2016; 47: 1399-1406
        • Hanley D.F.
        • Thompson R.E.
        • Muschelli J.
        • et al.
        Safety and efficacy of minimally invasive surgery plus alteplase in intracerebral haemorrhage evacuation (MISTIE): a randomised, controlled, open-label, phase 2 trial.
        Lancet Neurol. 2016; 15: 1228-1237
        • Hanley D.F.
        • Thompson R.E.
        • Rosenblum M.
        • et al.
        Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial.
        Lancet. 2019; 393: 1021-1032
        • Phillips V.L.
        • Roy A.K.
        • Ratcliff J.
        • et al.
        Minimally invasive parafascicular surgery (MIPS) for spontaneous intracerebral hemorrhage compared to medical management: a case series comparison for a single institution.
        Stroke Res Treat. 2020; 20206503038
      1. ENRICH: Early MiNimally-invasive Removal of IntraCerebral Hemorrhage (ICH) (ENRICH). 2016 [cited 2021 August 20, 2021]; The ENRICH trial will compare the outcomes between early surgical intervention using the BrainPath® Approach (i.e., MIPS) and a medically managed cohort. The integrated surgical approach includes a combination of available technologies, including the FDA-cleared NICO BrainPath® for non-disruptive access and NICO Myriad® to achieve the goal of maximum clot evacuation. The medically managed cohort will be treated according the Clinical Standardization Guidelines (CSG) as adapted by Emory University from the 2015 AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. Clinical efficacy will be determined by demonstrating a 10% improvement in functional outcome, as determined by a blinded-assessment of the 180-day utility-weighted modified Rankin Scale (mRS). Data suggests improved mortality rates and potential functional benefits of surgical ICH evacuation. The methodology proposed for this trial was tested in a preliminary series of 39 patients treated for supratentorial spontaneous ICH and retrospectively reviewed (Labib et al.). These results were replicated in a single center retrospective series of 18 patients (Bauer et al.). Despite positive results of both studies and the widely accepted benefit of the BrainPath Approach (i.e., MIPS) for subcortical lesions, stronger evidence supporting the use of these techniques in ICH is needed for the technique to become universally validated.]. Available from:

      2. INVEST Feasibility - Minimally Invasive Endoscopic Surgery With Apollo in Patients With Brain Hemorrhage. 2016 [cited 2021 August 20, 2021]; Objective: The primary objective of this multicenter single arm feasibility study is to provide an assessment of enrollment and follow up feasibility for this patient population being treated with the Apollo or Artemis Minimally Invasive Surgical Treatment (MIES). Patients who do not qualify for the INVEST Feasibility Study will be referred to the INVEST Registry study. Study Design: This study will be a prospective, multi-centered trial that will enroll 50 patients at up to 10 United States (US) centers. Patient Population: Patients with moderate-large volume (20-80 cc) supratentorial intracerebral hemorrhage (ICH) who present within 24 hours of symptom onset. Enrolled patients will receive minimally invasive endoscopic evacuation with the Apollo system or Artemis Device. Indication: The Artemis Neuro Evacuation Device is used for the controlled aspiration of tissue and/or fluid during surgery of the Ventricular System or Cerebrum in conjunction with a Penumbra Aspiration Pump. The Penumbra Aspiration Pump is indicated as a vacuum source for the Penumbra Aspiration Systems. The Apollo system has been cleared for the controlled aspiration of soft tissue and/or fluid during endoscopically guided neurosurgery of the ventricular system or cerebrum. In the present study, the researchers propose to investigate the feasibility of studying this patient population for eventual implementation of efficacy trials.]. Available from:

      3. MIND: Artemis in the Removal of Intracerebral Hemorrhage. 2017 [cited 2021; Subjects will be randomized to either minimally invasive hematoma evacuation with the Artemis Neuro Evacuation Device with medical management (MIS group) or best medical management alone (2:1) (MM).]. Available from:

        • Catalano A.R.
        • Winn H.R.
        • Gordon E.
        • et al.
        Impact of interhospital transfer on complications and outcome after intracranial hemorrhage.
        Neurocrit Care. 2012; 17: 324-333
        • Finn E.B.
        • Campbell Britton M.J.
        • Rosenberg A.P.
        • et al.
        A qualitative study of risks related to interhospital transfer of patients with nontraumatic intracranial hemorrhage.
        J Stroke Cerebrovasc Dis. 2019; 28: 1759-1766
        • Vahidy F.S.
        • Meyer E.G.
        • Bambhroliya A.B.
        • et al.
        Rationale and design of a statewide cohort to examine efficient resource utilization for patients with Intracerebral hemorrhage (EnRICH).
        BMC Neurol. 2018; 18: 31
        • Hemphill 3rd, J.C.
        • Bonovich D.C.
        • Besmertis L.
        • et al.
        The ICH score: a simple, reliable grading scale for intracerebral hemorrhage.
        Stroke. 2001; 32: 891-897
        • Clarke J.L.
        • Johnston S.C.
        • Farrant M.
        • et al.
        External validation of the ICH score.
        Neurocrit Care. 2004; 1: 53-60
        • Hemphill 3rd, J.C.
        • Farrant M.
        • Neill Jr., T.A.
        Prospective validation of the ICH Score for 12-month functional outcome.
        Neurology. 2009; 73: 1088-1094
        • Klaas J.P.
        • Braksick S.
        • Mandrekar J.
        • et al.
        Factors associated with the need for intensive care unit admission following supratentorial intracerebral hemorrhage: the triage ICH model.
        Neurocrit Care. 2017; 27: 75-81
        • Zachrison K.S.
        • Aaronson E.
        • Mahmood S.
        • et al.
        Resource utilisation among patients transferred for intracerebral haemorrhage.
        Stroke Vasc Neurol. 2019; 4: 223-226
        • Kilbourn K.J.
        • Levy S.
        • Staff I.
        • et al.
        Clinical characteristics and outcomes of neurogenic stress cadiomyopathy in aneurysmal subarachnoid hemorrhage.
        Clin Neurol Neurosurg. 2013; 115: 909-914
        • Nguyen C.
        • Mir O.
        • Vahidy F.
        • et al.
        Resource utilization for patients with intracerebral hemorrhage transferred to a comprehensive stroke center.
        J Stroke Cerebrovas Dis. 2015; 24: 2866-2874
        • Vahidy F.
        • Albright K.
        • Donnelly J.P.
        • et al.
        National trends in transfer of patients with intracerebral hemorrhage to teaching hospitals.
        Stroke. 2016; : 47