Heidelberg bleeding classification

Last revised by Rohit Sharma on 22 Feb 2024

The Heidelberg bleeding classification categorizes intracranial hemorrhages (hemorrhagic transformation) occurring after ischemic stroke and reperfusion therapy.

Anatomic description

  • Class 1: hemorrhagic transformation of infarcted brain tissue

    • 1a: HI1: scattered small petechiae, no mass effect

    • 1b: HI2: confluent petechiae, no mass effect

    • 1c: PH1: hematoma within infarcted tissue, occupying <30%, no substantive mass effect

  • Class 2: intracerebral hemorrhage within and beyond infarcted brain tissue

    • PH2: hematoma occupying ≥30% of the infarcted tissue, with obvious mass effect (PH2)

  • Class 3: intracerebral hemorrhage outside the infarcted brain tissue or intracranial-extracerebral hemorrhage

HI indicates hemorrhagic infarction; PH indicates parenchymatous hematoma. This terminology is borrowed from the ECASS (European Cooperative Acute Stroke Study) II classification of hemorrhagic transformation on an ischemic infarct.

Identification of symptomatic intracranial hemorrhage

The Heidelberg group recommends brain imaging within 48 hours of reperfusion therapy and thereafter during the hospitalization based on new neurologic symptoms.

After the identification and anatomic description of an intracranial hemorrhage, it is further classified as symptomatic or asymptomatic:

  • symptomatic intracranial hemorrhage (SICH) is new intracranial hemorrhage associated with any of the following:

    • ≥4 point increase in the NIH Stroke Scale (compared to the immediate pre-deterioration status)

    • ≥2 point increase in one NIH Stroke Scale subcategory

    • leading to major medical/surgical intervention such as intubation, hemicraniectomy, or external ventricular drain placement

    • absence of an alternative explanation for deterioration

  • asymptomatic intracranial hemorrhage (aSICH) is new intracranial hemorrhage without substantive change in the patient's neurologic status and has no implications for prognosis or change in management

Symptomatic hemorrhages are considered definite if any intracranial hemorrhage is the dominant brain pathology on imaging causal for deterioration. However, in some cases, the causality is not certain because the ischemic infarct may have contributed to the deterioration, so the following classifications are applied for trial and registry reporting purposes:

  • symptomatic

    • probable relatedness: class 2 (PH2) hemorrhage

  • asymptomatic

    • possible relatedness: class 1b (HI2), 1c (PH1), and 3 hemorrhages

    • unlikely relatedness: class 1a (HI1) hemorrhage

The relatedness to intervention is further specified following thrombolytic administration or endovascular therapy by the certainty of relatedness:

  • definite: observed procedural complication (eg, perforation of artery during angiography)

  • probable: treatment within last 24 hours and class 1c or 2 hemorrhage (PH) (symptomatic or asymptomatic)

  • possible: treatment within last 24 hours and class 1a or 1b hemorrhage (HI) (symptomatic or asymptomatic)

  • unrelated: no intervention in the 24 hours prior to hemorrhage detection

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