What is the management and treatment approach for a patient presenting with symptoms of intracerebral hemorrhage (ICH)?

Management and Treatment of Intracerebral Hemorrhage (ICH)

Immediate and aggressive management of intracerebral hemorrhage is essential as early deterioration is common in the first few hours after onset, with over 20% of patients experiencing a decrease in Glasgow Coma Scale (GCS) of two or more points between prehospital assessment and emergency department evaluation. 1

Prehospital Management

• Primary objectives:
  • Provide ventilatory and cardiovascular support
  • Transport patient to closest facility prepared to care for acute stroke patients 1
  • Obtain focused history on timing of symptom onset and medical history
  • Provide advance notice to ED to initiate critical pathways and alert consulting services

Emergency Department Management

Immediate Assessment

• Rapid neuroimaging with CT or MRI to distinguish ICH from ischemic stroke (Class I; Level of Evidence A) 1
• Baseline severity score as part of initial evaluation (Class I; Level of Evidence B) 1
• Clinical evaluation should be performed efficiently with physicians and nurses working in parallel 1

Blood Pressure Management

• For ICH patients with SBP between 150-220 mmHg without contraindications:
  • Acute lowering of SBP to 140 mmHg is safe (Class I; Level of Evidence A) 1
  • Intensive BP lowering within six hours of onset reduces risk of hematoma expansion 2

Reversal of Anticoagulation

• For patients on anticoagulants, immediate reversal is critical:
  • Vitamin K antagonists (e.g., warfarin): Administer 4-factor PCC with intravenous vitamin K 1
  • Direct thrombin inhibitors: Use idarucizumab for dabigatran 1
  • Factor Xa inhibitors: Use andexanet alfa 1
  • Heparin: Administer protamine 1

Management of Coagulopathy

• Patients with severe coagulation factor deficiency or thrombocytopenia should receive appropriate factor replacement or platelets (Class I; Level of Evidence C) 1
• Reversal should be administered when clinically significant anticoagulant levels are suspected rather than waiting for blood test results 1

Critical Care Management

Monitoring and Care Setting

• Initial monitoring and management should take place in an ICU or dedicated stroke unit with physician and nursing neuroscience acute care expertise (Class I; Level of Evidence B) 1
• Admission to a neuroscience ICU may result in reduced mortality 1

Intracranial Pressure (ICP) Management

• For patients with clinical evidence of increased ICP:
  • Multimodal monitoring to assess metabolic and hemodynamic variables 1
  • Maintain cerebral perfusion pressure (CPP) between 50-70 mmHg 2
  • Use osmotic agents like mannitol or glycerol to reduce ICP 3
  • Consider CSF drainage via intraventricular catheter for hydrocephalus 1

Prevention of Complications

• Intermittent pneumatic compression for prevention of venous thromboembolism beginning on day of admission (Class I; Level of Evidence A) 1
• Avoid graduated compression stockings for DVT prophylaxis 2
• Pharmacological prophylaxis can be initiated 24-48 hours after hematoma stability is documented 2
• Formal screening for dysphagia before initiating oral intake (Class I; Level of Evidence B) 1
• Monitor glucose and avoid both hyperglycemia and hypoglycemia (Class I; Level of Evidence C) 1

Seizure Management

• Treat clinical seizures with antiseizure drugs (Class I; Level of Evidence A) 1
• Treat electrographic seizures detected on EEG in patients with altered mental status (Class I; Level of Evidence C) 1

Surgical Management

• Cerebellar hemorrhage: Patients who are deteriorating neurologically or have brainstem compression and/or hydrocephalus should undergo surgical removal as soon as possible (Class I; Level of Evidence B) 1
• Supratentorial ICH: Benefit of surgery is less well established (Class IIb, Level of Evidence A) 2
• Consider early surgery (within 96 hours) for patients with:
  • GCS score of 9-12
  • Hematomas extending to within 1 cm of cortical surface
  • Significant midline shift or elevated ICP refractory to medical management 2

Long-term Management

• Blood pressure should be controlled in all ICH patients (Class I; Level of Evidence A) 1
• BP control measures should begin immediately after ICH onset (Class I; Level of Evidence A) 1
• All patients should have access to multidisciplinary rehabilitation (Class I; Level of Evidence A) 1

Prognostic Factors

• Poor prognostic factors include:
  • Larger hematoma volume
  • Lower initial GCS score
  • Presence of intraventricular hemorrhage 2
• 30-day mortality rate: 35-52%
• Only about 20% of patients achieve functional independence after 6 months 2

Common Pitfalls to Avoid

• Delaying neuroimaging - CT should be completed within 45 minutes of ED arrival 2
• Waiting for coagulation test results before initiating reversal therapy in anticoagulated patients 1
• Neglecting to control blood pressure early, which increases risk of hematoma expansion 1
• Failing to recognize patients who need urgent surgical intervention, particularly those with cerebellar hemorrhage 1
• Using steroids, which provide no benefit in ICH management 3

Recent evidence from 2023-2024 shows promising results for hyperacute care bundle approaches, early minimally invasive hematoma evacuation, and improved anticoagulation reversal strategies, suggesting we are entering a new era of more effective ICH management 4.