What is the evidence-based treatment for intracerebral hemorrhage (ICH)?

Evidence-Based Treatment for Intracerebral Hemorrhage (ICH)

All patients with acute ICH should be managed in an acute stroke unit or neuroscience intensive care unit, with immediate blood pressure control targeting systolic BP <140 mmHg within 1 hour if presenting with SBP 150-220 mmHg, rapid reversal of any coagulopathy, and intermittent pneumatic compression for DVT prophylaxis. 1, 2

Immediate Care Setting and Monitoring

• Admit all ICH patients to an acute stroke unit or neuroscience ICU with specialized nursing and physician expertise, as this reduces both death and dependency compared to general ward care 1, 2
• Perform continuous cardiopulmonary monitoring including automated BP cuff, EKG telemetry, and oxygen saturation 1
• Obtain immediate CT imaging to confirm diagnosis and assess hematoma volume 2
• Consider CT angiography to identify patients at risk for hematoma expansion 2
• Perform baseline severity assessment using Glasgow Coma Scale or NIH Stroke Scale 2

Blood Pressure Management

The most critical acute intervention is aggressive BP lowering to prevent hematoma expansion:

• For patients with SBP 150-220 mmHg, immediately lower systolic BP to <140 mmHg within 1 hour of presentation 1, 2
• This intensive BP reduction is safe and may improve functional outcomes based on the INTERACT-2 trial 1
• Use locally available IV antihypertensive agents according to institutional preference 1
• Avoid BP reductions ≥60 mmHg within 1 hour, as overly rapid drops may worsen outcomes 3
• Maintain sustained BP control for at least 24 hours, minimizing variability 3
• For patients with elevated ICP, maintain cerebral perfusion pressure >70 mmHg 1

Reversal of Coagulopathy

Immediate reversal of anticoagulation is essential to prevent hematoma expansion:

For Warfarin/Vitamin K Antagonists:

• Administer prothrombin complex concentrates (PCCs) immediately—this is preferred over fresh frozen plasma for rapid INR correction 2, 3
• Give intravenous vitamin K 2
• Withhold the warfarin 2

For Direct Oral Anticoagulants:

• Dabigatran: administer idarucizumab 3
• Anti-Xa agents (rivaroxaban, apixaban): use andexanet alfa where available, or PCC as alternative 3

For Severe Thrombocytopenia or Coagulation Factor Deficiency:

• Provide appropriate platelet transfusion or factor replacement therapy 2

Prevention of Venous Thromboembolism

• Use intermittent pneumatic compression starting on day of admission for all immobile ICH patients 1, 2
• Avoid graduated compression stockings alone, as they are less effective 1
• Do NOT use hemostatic therapy (such as recombinant factor VIIa) for acute ICH not associated with antithrombotic drug use, as this provides no benefit and may increase thrombotic complications 1

Management of Elevated Intracranial Pressure

Use a graded approach when ICP is elevated:

• Begin with simple measures: elevate head of bed 30 degrees, provide adequate analgesia and sedation 1
• Progress to more aggressive therapies if needed: osmotic diuretics (mannitol or hypertonic saline), CSF drainage via external ventricular drain, neuromuscular blockade, and hyperventilation 1
• These aggressive measures require concomitant ICP monitoring with goal CPP >70 mmHg 1

Surgical Interventions

Cerebellar Hemorrhage:

• Patients with cerebellar ICH who are deteriorating neurologically OR have brainstem compression and/or hydrocephalus should undergo immediate surgical evacuation 2

Supratentorial ICH:

• Consider early surgery for patients with Glasgow Coma Scale score 9-12 1
• Minimally invasive hematoma evacuation shows promise for lobar ICH but requires further validation 4, 5

Intraventricular Hemorrhage:

• External ventricular drainage with intraventricular fibrinolysis (with or without lumbar drainage) is effective 6, 4

Prevention of Secondary Complications

Seizure Management:

• Treat clinical seizures with antiseizure medications 2
• Patients with electrographic seizures on EEG and altered mental status should receive antiseizure drugs 2
• Consider brief prophylactic antiepileptic therapy for lobar hemorrhages to reduce early seizure risk 1

Glucose Management:

• Treat persistent hyperglycemia >140 mg/dL, as this is associated with poor outcomes 1
• Administer insulin for glucose >185 mg/dL (and possibly >140 mg/dL) 1
• Avoid hypoglycemia 2

Aspiration Prevention:

• Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk 2

Temperature Management:

• Treat fever sources and administer antipyretics in febrile patients 1

Interventions to AVOID

• Do NOT use corticosteroids for ICH management, as they provide no benefit 1
• Do NOT use hemostatic therapy (rFVIIa) outside of coagulopathy reversal, as phase III trials have not confirmed benefit 1
• Avoid graduated compression stockings alone for DVT prophylaxis 1

Long-Term Management and Rehabilitation

• Control blood pressure long-term for secondary prevention 1
• Provide access to multidisciplinary rehabilitation services for all ICH patients 2
• Begin early mobilization and rehabilitation once clinically stable 1

Critical Pitfalls to Avoid

• Avoid overly pessimistic early prognostication in the first 24-48 hours, as this may deny patients meaningful recovery achievable with specialized neurocritical care 4, 3
• Do not delay neuroimaging, as hematoma expansion commonly occurs within the first few hours 2
• Do not fail to investigate secondary causes (vascular malformations, tumors, cerebral venous thrombosis) in patients with atypical presentations or unusual hemorrhage locations 2
• Avoid early do-not-resuscitate orders or withdrawal of care in the first 24-48 hours, as early prognostication is difficult 3