How should hemorrhagic stroke be managed acutely and for secondary prevention, including airway support, blood pressure control, anticoagulation reversal, intracranial pressure control, surgical indications, and preventive measures?

Hemorrhagic Stroke Management

For acute hemorrhagic stroke, immediately implement bundled care within 60 minutes: stabilize airway if GCS ≤8, lower systolic BP to <140 mmHg within 1 hour, reverse any coagulopathy emergently, and consider surgical evacuation for cerebellar hemorrhage ≥15 mL or deteriorating supratentorial ICH as a lifesaving measure.

Immediate Airway and Vital Function Stabilization

Secure the airway if Glasgow Coma Scale ≤8 or if there are signs of impending herniation 1. This takes priority over all other interventions as it prevents secondary brain injury from hypoxia.

Acute Blood Pressure Management

• Target systolic BP <140 mmHg within 1 hour of presentation 1, 2
• This rapid, aggressive BP lowering prevents hematoma expansion, which is the primary driver of early deterioration
• Use IV antihypertensives with titratable agents (nicardipine, labetalol, clevidipine)
• The evidence strongly supports early intensive BP lowering as a cornerstone of acute ICH management

Coagulopathy Reversal

Reverse anticoagulation immediately upon diagnosis 1, 3:

• For warfarin: Give 4-factor prothrombin complex concentrate (PCC) plus IV vitamin K
• For direct oral anticoagulants: Use specific reversal agents (idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors)
• Avoid platelet transfusions for antiplatelet-associated ICH - weak evidence shows this may worsen outcomes 2

The guideline evidence indicates platelet transfusions should not be routinely given, contrary to older practice patterns.

Intracranial Pressure Management

Monitor for signs of elevated ICP (deteriorating consciousness, pupillary changes, Cushing's triad):

• Give hyperosmolar therapy immediately (mannitol or hypertonic saline) if clinical herniation signs present 1
• Place external ventricular drain (EVD) emergently for hydrocephalus 4
• Elevate head of bed 30 degrees
• Avoid EVD alone for cerebellar ICH with compressed basal cisterns - this can worsen herniation 4

Surgical Indications

Cerebellar Hemorrhage (Class I Recommendation)

Perform immediate surgical evacuation ± EVD for cerebellar ICH if ANY of the following 4:

• Neurological deterioration
• Brainstem compression on imaging
• Hydrocephalus from ventricular obstruction
• Hematoma volume ≥15 mL

This is the strongest surgical recommendation with Class I evidence - it reduces mortality significantly.

Supratentorial ICH

Consider craniotomy as a lifesaving measure only if the patient is actively deteriorating 4. The evidence from STICH I and II trials shows no overall functional benefit from routine craniotomy, but there may be a mortality benefit in deteriorating patients. The 21% crossover rate in STICH II (mostly due to deterioration) suggests surgery can be lifesaving in this specific scenario.

Minimally invasive surgery shows promise for lobar ICH and may improve both survival and functional outcomes 1, 5, though this remains an evolving area.

Intraventricular Hemorrhage

Use EVD plus intraventricular thrombolysis (with or without lumbar drainage) for significant IVH 5. This combination effectively clears blood and reduces complications.

Prevention of Medical Complications

• Apply intermittent pneumatic compression to prevent deep vein thrombosis 2
• Do NOT give prophylactic antiseizure medications routinely - only treat if seizures occur 2
• Do NOT give prophylactic antibiotics 2
• Monitor and manage glucose, but temperature and glucose control as isolated measures lack strong evidence 2

Critical Pitfalls to Avoid

Avoid early therapeutic nihilism - prognostication should be delayed for at least the first few days to allow time for recovery 1. Early pessimism becomes a self-fulfilling prophecy when care is withdrawn prematurely 3.

Do not use recombinant factor VIIa routinely - strong evidence shows no benefit 2.

Do not use anti-inflammatory drugs outside clinical trials - strong evidence against this 2.

Secondary Prevention

Once stabilized:

• Maintain sustained blood pressure control long-term - this is strongly recommended for secondary prevention 2
• Consider antiplatelet therapy for licensed indications only after careful risk-benefit assessment 2
• Address modifiable risk factors (hypertension is the primary driver of ICH recurrence)

Time-Based Care Bundle ("Code ICH")

The concept of bundled care within 60 minutes mirrors the urgency of ischemic stroke protocols 1:

1. BP lowering initiated
2. Coagulopathy reversed
3. Neuroimaging completed
4. Neurosurgical consultation obtained if indicated

This systematic approach to acute ICH management, prioritizing rapid BP control and coagulopathy reversal while avoiding therapeutic nihilism, represents the current evidence-based standard of care.