What is the management of intracerebral hemorrhage (ICH)?

Management of Intracerebral Hemorrhage (ICH)

Intracerebral hemorrhage requires immediate aggressive care in an acute stroke unit or neuroscience ICU with rapid diagnosis, blood pressure control, reversal of coagulopathy, prevention of secondary brain injury, and consideration for surgical intervention in select cases. 1

Initial Assessment and Diagnosis

• Rapid neuroimaging: Non-contrast CT scan should be completed within 45 minutes of ED arrival to distinguish ICH from ischemic stroke 1
• Baseline severity assessment: Document GCS score and NIH Stroke Scale 1
• Early deterioration monitoring: Critical as over 20% of patients experience a decrease in GCS of ≥2 points between prehospital assessment and ED evaluation 1
• Consider CT angiography: To evaluate for underlying vascular abnormalities 1

Acute Management

Blood Pressure Control

• Target: Intensive lowering of systolic BP to <140 mmHg within 6 hours of ICH onset 1
• Method: Intravenous antihypertensive medications with continuous BP monitoring
• Caution: Avoid reductions ≥60 mmHg within 1 hour to prevent cerebral hypoperfusion 2

Coagulopathy Reversal

• For vitamin K antagonists: Administer prothrombin complex concentrate (preferred over FFP) plus vitamin K 1, 2
• For direct oral anticoagulants:
  • Dabigatran: Idarucizumab
  • Factor Xa inhibitors: PCC or andexanet alfa (where available) 2
• Timing: Immediate reversal is critical to prevent hematoma expansion 2

Hemostatic Therapy

• For non-anticoagulated patients: Avoid hemostatic therapy 1
• Ultra-early hemostatic therapy: May reduce early hematoma expansion in selected patients 3, 4

Prevention of Secondary Brain Injury

Intracranial Pressure (ICP) Management

• Osmotic agents: Mannitol or hypertonic saline for elevated ICP 3
• Head position: Elevate head of bed to 30 degrees
• Avoid: Routine hyperventilation, steroids, and prophylactic antiseizure medications 1

Venous Thromboembolism Prophylaxis

• Recommended: Intermittent pneumatic compression beginning on day of admission 1
• Avoid: Graduated compression stockings 1

Other Medical Management

• Glucose control: Monitor and avoid both hyperglycemia and hypoglycemia 1
• Seizure management: Treat clinical seizures with antiseizure medications 1
• Dysphagia screening: Before initiating oral intake 1
• Temperature control: Treat fever >38°C with antipyretics

Surgical Interventions

Indications for Surgery

• Early surgery (within 8 hours) for patients with GCS 9-12 1
• Consider evacuation for:
  • Cerebellar hemorrhage >3 cm with neurological deterioration
  • Hydrocephalus with intraventricular hemorrhage (external ventricular drain)
  • Large hematomas with significant mass effect or midline shift 5

Surgical Approaches

• Traditional craniotomy: Not shown to improve outcomes in most cases 5
• Minimally invasive techniques: May be beneficial in selected patients 5
• External ventricular drainage: For hydrocephalus management 2, 6

Care Setting and Monitoring

• Location: Dedicated stroke unit or neuroscience ICU with specialized nursing and physician expertise 1
• Monitoring: Frequent neurological assessments, vital signs, and ICP monitoring when indicated
• Bundle of care approach: Implementing comprehensive protocols for consistent management 2

Prognostic Factors

• Poor prognostic indicators: Large hematoma volume, low initial GCS, presence of intraventricular hemorrhage 7
• Mortality rates: 30-day mortality 35-52%, with only 20% achieving functional independence at 6 months 7
• Avoid: Early do-not-resuscitate orders or withdrawal of care in the first 24-48 hours 2

Rehabilitation and Secondary Prevention

• Multidisciplinary rehabilitation: Should be initiated early 1
• Blood pressure control: For secondary prevention 1
• Lifestyle modifications: Smoking cessation, alcohol moderation, diet management

Common Pitfalls to Avoid

• Delaying diagnosis and treatment (early deterioration is common)
• Inadequate reversal of anticoagulation
• Excessive blood pressure reduction causing cerebral hypoperfusion
• Premature prognostication leading to early withdrawal of care
• Neglecting VTE prophylaxis
• Using steroids (no benefit in ICH management) 1

ICH management requires a coordinated, multidisciplinary approach with attention to both immediate stabilization and prevention of secondary complications to improve patient outcomes.