What are the guidelines for managing spontaneous intracerebral hemorrhage (ICH)?

Guidelines for Managing Spontaneous Intracerebral Hemorrhage (ICH)

The management of spontaneous intracerebral hemorrhage requires immediate intervention in a specialized stroke unit or neuroscience ICU, with aggressive blood pressure control to SBP <140 mmHg within six hours of onset, appropriate coagulopathy reversal, prevention of complications, and consideration for surgical intervention in select cases. 1

Initial Assessment and Diagnosis

• Rapid neuroimaging with CT or MRI is mandatory to distinguish ICH from ischemic stroke, with CT being the gold standard for identifying acute hemorrhage 1, 2
• A baseline severity score (such as Glasgow Coma Scale or NIH Stroke Scale) should be performed as part of the initial evaluation 1, 2
• CT angiography and contrast-enhanced CT may help identify patients at risk for hematoma expansion 2
• Every emergency department should be prepared to treat ICH patients or have a plan for rapid transfer to a tertiary care center 1

Acute Management

Blood Pressure Control

• For ICH patients presenting with SBP between 150-220 mmHg without contraindications, acute lowering of SBP to 140 mmHg is safe and can improve functional outcomes 1
• BP control measures should begin immediately after ICH onset 1
• For patients with SBP >220 mmHg, aggressive reduction with continuous intravenous infusion and frequent BP monitoring may be reasonable 1

Hemostasis and Coagulopathy Management

• Patients with severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets 1, 2
• For patients on vitamin K antagonists (VKAs) with elevated INR, rapidly correct coagulopathy by withholding the VKA, administering therapy to replace vitamin K-dependent factors, and providing intravenous vitamin K 1, 2
• Prothrombin complex concentrates are preferred over fresh frozen plasma for rapid INR correction in VKA-related ICH 2
• Avoid hemostatic therapy for ICH not associated with antithrombotic drug use 1

Hospital Care Setting

• Initial monitoring and management should take place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise 1
• Glucose should be monitored, avoiding both hyperglycemia and hypoglycemia 1

Prevention of Secondary Complications

• Use intermittent pneumatic compression for prevention of venous thromboembolism beginning on the day of hospital admission 1
• Avoid graduated compression stockings 1
• Treat clinical seizures with antiseizure drugs 1
• Patients with electrographic seizures on EEG and altered mental status should receive antiseizure drugs 1
• Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk 1
• Avoid corticosteroids in ICH management 1, 2

Surgical Management

• Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus should undergo surgical removal of the hemorrhage as soon as possible 1
• Consider early surgery for patients with Glasgow Coma Scale score 9-12 1, 2
• Ventriculostomy is indicated for patients with severe intraventricular hemorrhage, hydrocephalus, or elevated intracranial pressure 3

Prevention of Recurrent ICH

• Blood pressure should be controlled in all ICH patients long-term 1
• Pharmacological venous thromboembolism prophylaxis can be initiated after documenting hemorrhage stability, typically 24-48 hours after ICH onset 3

Rehabilitation

• All ICH patients should have access to multidisciplinary rehabilitation services 1
• Rehabilitation should begin as early as possible and continue in the community as part of a coordinated program 4

Common Pitfalls and Caveats

• Delaying neuroimaging can lead to missed opportunities for intervention, as hematoma expansion commonly occurs within the first few hours after onset 2, 3
• Failing to correct coagulopathy rapidly in patients on anticoagulants can lead to continued hematoma expansion and worse outcomes 2, 5
• Overlooking secondary causes of ICH (vascular malformations, tumors, cerebral vein thrombosis) in patients with atypical presentations or hemorrhage locations 2, 6
• Transfusion of platelets in patients on antiplatelet therapy is not indicated unless the patient is scheduled for surgical evacuation of hematoma 3