What are the management strategies for Intracerebral Hemorrhage (ICH)?

Management of Intracerebral Hemorrhage (ICH)

All patients with acute ICH should be managed in an acute stroke unit or intensive care unit with neuroscience expertise, with immediate focus on blood pressure control, coagulopathy reversal, and prevention of hematoma expansion to reduce mortality and improve functional outcomes. 1, 2

Initial Assessment and Stabilization

Neuroimaging and Diagnosis

• Obtain immediate CT scan without contrast as the gold standard for diagnosing acute ICH and distinguishing it from ischemic stroke 1, 2
• Perform CT angiography to identify patients at risk for hematoma expansion and to detect underlying vascular abnormalities 1
• Document baseline severity using Glasgow Coma Scale (GCS) or NIH Stroke Scale immediately upon presentation 1

Hospital Setting

• Admit to an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise 1
• Every emergency department must be prepared to treat ICH or have a rapid transfer plan to a tertiary care center 1

Acute Blood Pressure Management

For patients presenting with systolic BP 150-220 mmHg within 6 hours of onset, immediately lower systolic BP to <140 mmHg, as this is safe and improves functional outcomes. 1, 2

• Begin BP control measures immediately after ICH diagnosis 1
• Avoid excessive BP reduction (≥60 mmHg within 1 hour) as this may worsen outcomes 3
• Maintain careful, targeted, and sustained BP control during the first 24 hours, minimizing variability 3
• For unsecured aneurysms, maintain systolic BP <160 mmHg while avoiding hypotension (systolic <110 mmHg) 2

Common pitfall: Hypertension is associated with hematoma expansion, which predicts clinical deterioration and increased mortality, making rapid BP control critical 2

Reversal of Coagulopathy

Immediately reverse anticoagulation in all patients on anticoagulants with ICH, as this reduces hematoma expansion and may improve outcomes. 2, 3

Vitamin K Antagonists (Warfarin)

• Administer four-factor prothrombin complex concentrate (PCC) immediately 1, 2
• Give intravenous vitamin K 1, 2
• PCC is preferred over fresh frozen plasma for rapid INR correction 1

Direct Thrombin Inhibitors (Dabigatran)

• Administer idarucizumab as first-line reversal agent 2, 3
• If idarucizumab unavailable, consider hemodialysis 2

Factor Xa Inhibitors (Rivaroxaban, Apixaban, Edoxaban)

• Administer four-factor PCC (50 U/kg) or activated PCC (50 U/kg) 2
• Andexanet alfa may be used where available 3

Heparin

• Administer protamine sulfate at 1 mg for every 100 units of heparin given in the previous 2-3 hours (maximum single dose 50 mg) 2

Thrombocytopenia and Coagulation Factor Deficiency

• Patients with severe thrombocytopenia should receive platelet transfusion 1
• Patients with severe coagulation factor deficiency should receive appropriate factor replacement therapy 1

Management of Increased Intracranial Pressure

General Measures

• Elevate head of bed to 30 degrees for patients with evidence of increased ICP 2
• Use 0.9% saline as the crystalloid solution; avoid hypotonic fluids to prevent worsening cerebral edema 2, 4

ICP Monitoring

• Consider ICP monitoring in patients with GCS ≤8, hydrocephalus, or clinical evidence of transtentorial herniation 1, 2, 4

Osmotic Therapy

• Administer mannitol or hypertonic saline to produce hyperosmolality and euvolemia in patients with elevated ICP 4, 5
• Mannitol dosing for adults: 0.25 to 2 g/kg body weight as a 15% to 25% solution over 30 to 60 minutes 5
• Mannitol dosing for pediatric patients: 1 to 2 g/kg body weight or 30 to 60 g/m² body surface area over 30 to 60 minutes 5

Hydrocephalus Management

• Perform CSF drainage via external ventricular drainage for patients with hydrocephalus or ventricular obstruction 4
• Intraventricular hemorrhage can be effectively treated with external ventricular drainage and intraventricular fibrinolysis, with or without additional lumbar drainage 6

Common pitfall: Avoid medications that cause cerebral vasodilation or increase cerebral blood volume in acute ICH, as these worsen intracranial compliance and can precipitate herniation 4

Surgical Management

Cerebellar Hemorrhage

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, 2

Supratentorial ICH

• Consider early surgery for patients with GCS score 9-12 7, 1
• Patients with hematomas extending to within 1 cm of the cortical surface may benefit from surgery within 96 hours 2
• Minimally invasive procedures for hematoma removal have potential to improve outcomes in lobar ICH 6

Prevention of Secondary Complications

Venous Thromboembolism Prophylaxis

• Initiate intermittent pneumatic compression on the day of hospital admission for all immobile patients 7, 1
• Avoid graduated compression stockings as they are not beneficial 7
• Begin pharmacologic DVT prophylaxis once bleeding has stabilized 2

Seizure Management

• Treat clinical seizures with antiseizure medications 1
• Administer antiseizure drugs to patients with electrographic seizures on EEG and altered mental status 1

Glucose Management

• Monitor and manage glucose levels, avoiding both hyperglycemia and hypoglycemia 1

Dysphagia Screening

• Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk 1

Medical Complications

• Monitor for and manage pneumonia, cardiac events, and acute kidney injury 2

Interventions to AVOID

Do NOT use the following interventions, as they are contraindicated or harmful:

• Hemostatic therapy for acute ICH not associated with antithrombotic drug use 7
• Corticosteroids - specifically contraindicated in ICH management 7, 4
• Acetazolamide 4
• Graduated compression stockings 7

Long-Term Secondary Prevention

Blood Pressure Control

• Control blood pressure long-term in all ICH patients as the most important target for preventing recurrence 1, 2
• Treated hypertension has an odds ratio of only 1.4 compared to 3.5 for untreated hypertension 2

Lifestyle Modifications

• Strongly discourage smoking, heavy alcohol use, and cocaine use after ICH 2

Rehabilitation

• All ICH patients should have access to multidisciplinary rehabilitation services 1

Prognostic Considerations

• ICH volume and GCS score on admission are the most powerful predictors of 30-day mortality 2
• One-month case fatality is 40%, increasing to 54% at one year 7
• Early aggressive care is warranted as most patients present with small ICHs that are readily survivable with good medical care 2
• Avoid early do-not-resuscitate orders or withdrawal of active care in the first 24-48 hours, as early prognostication is difficult 3

Critical Pitfalls to Avoid

• Delaying neuroimaging can lead to missed opportunities for intervention, as hematoma expansion commonly occurs within the first few hours 1
• Failing to rapidly correct coagulopathy in anticoagulated patients leads to continued hematoma expansion and worse outcomes 1, 2
• Overlooking secondary causes of ICH (vascular malformations, tumors, cerebral vein thrombosis) in patients with atypical presentations or hemorrhage locations 1
• Using nephrotoxic drugs or other diuretics concomitantly with mannitol, as this increases the risk of renal failure 5