Neuroradiology · Post-reperfusion haemorrhage · 1.0
Heidelberg Bleeding Classification
A combined radiological–clinical system for classifying intracranial haemorrhage after ischaemic stroke reperfusion therapy, extending ECASS by adding remote, intraventricular, subarachnoid and subdural bleeding categories and symptomatic/asymptomatic criteria.
Purpose
Standardises the anatomic description and clinical relevance of intracranial haemorrhage occurring after ischaemic stroke treated with thrombolysis and/or endovascular therapy, for use in trial reporting, registries and clinical practice.
| Class | Type | Description |
|---|---|---|
| 1a | HI1 | Scattered small petechiae, no mass effect |
| 1b | HI2 | Confluent petechiae, no mass effect |
| 1c | PH1 | Haematoma within infarcted tissue, occupying <30% of the infarct, no substantive mass effect |
| 2 | PH2 | Haematoma occupying ≥30% of the infarcted tissue, with obvious mass effect |
| 3a | Remote PH | Parenchymal haematoma remote from the infarcted brain tissue |
| 3b | IVH | Intraventricular haemorrhage |
| 3c | SAH | Subarachnoid haemorrhage |
| 3d | SDH | Subdural haemorrhage |
How to use it
- Class 1 (1a-1c) is haemorrhagic transformation confined within the infarcted tissue; Class 2 (PH2) is haemorrhage within and beyond the infarct with obvious mass effect; Class 3 (3a-3d) is haemorrhage outside the infarcted tissue or intracranial-extracerebral haemorrhage.
- Only PH2 (class 2) is consistently and independently associated with early neurological deterioration and worse prognosis among the anatomic categories.
- After anatomic classification, every bleed is separately labelled symptomatic (sICH) or asymptomatic based on NIHSS change: sICH requires a ≥4-point total NIHSS increase or a ≥2-point increase in one NIHSS subcategory, or a haemorrhage leading to major medical/surgical intervention (e.g. intubation, hemicraniectomy, external ventricular drain), with no alternative explanation for deterioration.
- For trial and registry reporting, relatedness of the haemorrhage to clinical deterioration is graded: class 2 (PH2) is probably related if symptomatic; classes 1b, 1c and 3 are possibly related; class 1a is considered unlikely related.
- The classification replaces the older ECASS HI1/HI2/PH1/PH2 scheme (which it retains within Class 1 and 2) by adding categories for remote parenchymal haematoma, IVH, SAH and SDH that ECASS did not separately capture.
Common mistake
Reporting only the ECASS-style HI/PH grade and omitting the class 3 subtypes (remote PH, IVH, SAH, SDH), or labelling any intracranial bleed as 'sICH' based on imaging appearance alone without applying the NIHSS-based symptomatic criteria.
Exam pearl
Only PH2 (class 2) is the anatomic category consistently linked to clinical deterioration - HI1/HI2/PH1 and isolated SAH are typically asymptomatic. When asked to define sICH under this system, anchor your answer to the NIHSS thresholds (≥4 total or ≥2 in one subcategory), not just 'any haemorrhage with worsening.'
Viva questions
- What does the Heidelberg Bleeding Classification classify, and why was it developed?
- It classifies intracranial haemorrhage after ischaemic stroke reperfusion therapy (thrombolysis or thrombectomy), extending the older ECASS HI/PH system by adding categories for remote parenchymal haematoma, intraventricular, subarachnoid and subdural haemorrhage, plus explicit symptomatic/asymptomatic criteria for trial reporting.
- List the Class 1 subtypes and their imaging definitions.
- 1a (HI1): scattered small petechiae, no mass effect. 1b (HI2): confluent petechiae, no mass effect. 1c (PH1): haematoma within the infarct occupying less than 30%, no substantive mass effect.
- How is Class 2 (PH2) defined, and why is it clinically important?
- PH2 is a haematoma occupying 30% or more of the infarcted tissue with obvious mass effect. It is the only anatomic category consistently and independently associated with clinical deterioration and worse prognosis.
- What are the four Class 3 subtypes?
- 3a: parenchymal haematoma remote from the infarcted tissue. 3b: intraventricular haemorrhage. 3c: subarachnoid haemorrhage. 3d: subdural haemorrhage.
- How is symptomatic intracranial haemorrhage (sICH) defined under this classification?
- A new intracranial haemorrhage associated with a total NIHSS increase of 4 points or more, or a 2-point increase in one NIHSS subcategory, or a haemorrhage leading to major medical or surgical intervention such as intubation, hemicraniectomy, or external ventricular drain placement, with no alternative explanation for the deterioration.
- How does this system grade relatedness of a haemorrhage to clinical deterioration for trial reporting?
- Class 2 (PH2) is graded as probably related when symptomatic. Classes 1b, 1c and 3 are graded as possibly related. Class 1a is graded as unlikely related.
- What is a common pitfall when applying this classification in practice or reporting?
- Reporting only the ECASS-equivalent HI/PH grade and omitting the class 3 subtypes, or calling a haemorrhage symptomatic based on imaging appearance alone rather than applying the defined NIHSS thresholds.
- How does the Heidelberg Bleeding Classification relate to the older ECASS HI/PH terminology?
- It retains the ECASS HI1, HI2, PH1 and PH2 labels within its Class 1 and Class 2, but adds Class 3 (remote PH, IVH, SAH, SDH) and formal symptomatic/asymptomatic and relatedness criteria that ECASS did not include.