What is the management of intracerebral hemorrhage?

Management of Intracerebral Hemorrhage

Intracerebral hemorrhage requires immediate aggressive medical management focused on preventing hematoma expansion through rapid blood pressure control to systolic <140 mmHg, immediate reversal of anticoagulation, and intensive monitoring in a neuroscience critical care unit. 1, 2

Emergency Assessment and Diagnosis

• Obtain non-contrast head CT immediately upon arrival to distinguish ICH from ischemic stroke—this is the gold standard for identifying acute hemorrhage 3, 2
• Perform baseline severity scoring using Glasgow Coma Scale (GCS) or NIH Stroke Scale as part of initial evaluation 1, 2
• Consider CT angiography to identify patients at risk for hematoma expansion, particularly looking for the "spot sign" which predicts ongoing bleeding 2
• Recognize that over 20% of patients deteriorate by ≥2 GCS points between prehospital assessment and ED arrival, and another 15-23% continue deteriorating in the first hours after hospital arrival 1, 3

Acute Blood Pressure Management

Lower systolic blood pressure to 140 mmHg immediately in patients presenting with SBP 150-220 mmHg without contraindications—this is safe and improves functional outcomes 2, 4

• Avoid rapid drops ≥60 mmHg within 1 hour, as this may worsen outcomes 5
• Target SBP as low as 120-130 mmHg for optimal functional outcomes in mild-to-moderate severity ICH 5
• Minimize blood pressure variability during the first 24 hours to prevent hematoma expansion 5
• Begin BP control measures immediately after ICH onset, as hematoma expansion commonly occurs within the first few hours 2

Reversal of Anticoagulation

Reverse anticoagulation immediately in all patients on anticoagulants, as this reduces hematoma expansion risk and may improve outcomes 5

For Vitamin K Antagonists (Warfarin):

• Administer prothrombin complex concentrate (PCC) as first-line therapy—this is preferred over fresh frozen plasma for rapid INR correction 2, 5
• Give intravenous vitamin K concurrently 2
• Withhold the warfarin 2

For Direct Oral Anticoagulants:

• Dabigatran: Administer idarucizumab 4, 5
• Factor Xa inhibitors (rivaroxaban, apixaban, edoxaban): Use andexanet alfa where available, or PCC as alternative 4, 5

For Thrombocytopenia or Platelet Dysfunction:

• Administer platelets to maintain platelet count above 50×10⁹/L in patients with ongoing bleeding 3

Intensive Care Unit Management

Admit all ICH patients to an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise 2, 6

Intracranial Pressure Management:

• Monitor ICP in patients with GCS ≤8, hydrocephalus, or clinical evidence of transtentorial herniation 3, 4
• Use osmotic agents (mannitol or hypertonic saline) to produce hyperosmolality and euvolemia in patients with elevated ICP 4
• Avoid acetazolamide in ICH management 4
• Use 0.9% saline as the crystalloid of choice to prevent worsening cerebral edema 4
• Avoid medications that cause cerebral vasodilation or increase cerebral blood volume, as these worsen intracranial compliance and can precipitate herniation 4

Prevention of Secondary Complications:

• Initiate intermittent pneumatic compression on the day of hospital admission for venous thromboembolism prophylaxis 2
• Begin pharmacological thromboprophylaxis within 24 hours after bleeding has been controlled 3
• Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk 2
• Treat clinical seizures with antiseizure medications 2
• Monitor and manage glucose levels, avoiding both hyperglycemia and hypoglycemia 2
• Manage fever aggressively as part of neuroprotective care 3

Surgical Management

Cerebellar Hemorrhage:

Perform immediate surgical evacuation in patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus from ventricular obstruction 3, 2

• This is the clearest surgical indication in ICH management 1, 2
• Do not use ventricular catheter alone instead of cerebellar hematoma evacuation, especially in patients with compressed cisterns 1

Supratentorial ICH:

• For most patients with supratentorial ICH, the usefulness of surgery is uncertain (Class IIb evidence) 3
• Consider early surgery for patients with lobar hemorrhages, GCS 9-12, and hematomas extending to within 1 cm of the cortical surface 1, 3, 2
• Minimally invasive procedures for hematoma removal show potential to improve outcomes in lobar ICH and deserve further evaluation 5, 7

Hydrocephalus Management:

• Perform external ventricular drainage (EVD) for patients with hydrocephalus or ventricular obstruction 4
• Consider intraventricular fibrinolysis with or without lumbar drainage for intraventricular hemorrhage, though this remains investigational 1, 8

Prognostication and Goals of Care

• Hematoma volume and admission GCS score are the most powerful predictors of 30-day mortality 3
• Avoid early do-not-resuscitate orders or withdrawal of active care in the first 24-48 hours, as early prognostication is difficult and often inaccurate 5, 6
• Use formal prognostic tools to offer information to patients and families rather than clinical gestalt alone 6
• Recognize that most patients present with small ICHs that are readily survivable with good medical care 1, 3

Contraindicated Interventions

Do not administer corticosteroids in ICH management—these are specifically contraindicated 2, 4

Rehabilitation

Provide access to multidisciplinary rehabilitation services for all ICH patients 2

Common Pitfalls

• Delaying neuroimaging leads to missed opportunities for intervention during the critical window when hematoma expansion occurs 2
• Failing to correct coagulopathy rapidly in anticoagulated patients allows continued hematoma expansion and worse outcomes 2
• Overlooking secondary causes of ICH (vascular malformations, tumors, cerebral venous thrombosis) in patients with atypical presentations or unusual hemorrhage locations 2
• Premature prognostication leading to early withdrawal of care in potentially salvageable patients 5, 6