What is the management of intracerebral hemorrhage?

Management of Intracerebral Hemorrhage

Immediate Emergency Response

Admit all patients with intracerebral hemorrhage to an acute stroke unit or neuroscience intensive care unit immediately, as this represents the single most strongly supported intervention to improve outcomes. 1

• Obtain non-contrast CT scan immediately upon arrival to confirm diagnosis and establish baseline hematoma volume, as this is the gold standard for acute hemorrhage detection 1, 2
• Perform baseline Glasgow Coma Scale (GCS) score, as this combined with hematoma volume represents the most powerful predictor of 30-day mortality 1, 3
• Anticipate early deterioration in over 20% of patients within the first few hours, manifesting as GCS decrease ≥2 points 4, 1
• Provide immediate airway management and cardiovascular support as needed 1
• Consider CT angiography to identify patients at risk for hematoma expansion 2

Blood Pressure Management

Target systolic blood pressure <140 mmHg within 6 hours of symptom onset using careful, sustained blood pressure lowering to prevent hematoma expansion. 1, 2

• For patients presenting with systolic BP 150-220 mmHg without contraindications, acute lowering to 140 mmHg is safe and improves functional outcomes 2
• Avoid aggressive reductions ≥60 mmHg within 1 hour, as this may compromise outcomes 5
• Minimize blood pressure variability during the first 24 hours for optimal functional outcomes 5
• Do not aggressively lower blood pressure in patients with suspected elevated intracranial pressure, as this may compromise cerebral perfusion pressure 1
• Maintain euvolemia throughout treatment 1

Reversal of Coagulopathy

For warfarin-associated ICH, administer prothrombin complex concentrate (PCC) immediately rather than fresh frozen plasma for rapid INR correction. 1, 2, 5

• Withhold vitamin K antagonists, administer PCC to replace vitamin K-dependent factors, and provide intravenous vitamin K 2
• For dabigatran-associated ICH, use idarucizumab as the specific reversal agent 1, 5
• For factor Xa inhibitor-associated ICH, use andexanet alfa where available, or PCC as alternative 1, 5
• Maintain platelet count >50×10⁹/L in patients with ongoing bleeding or traumatic brain injury 1, 3
• Correct severe coagulation factor deficiency with appropriate factor replacement therapy 2

Intracranial Pressure Management

Insert ICP monitoring device in patients with GCS ≤8, hydrocephalus, or clinical evidence of transtentorial herniation. 1, 3

• Elevate head of bed to 30° with head midline to improve jugular venous outflow, but only after excluding hypovolemia 1
• Target cerebral perfusion pressure ≥60-70 mmHg when managing elevated ICP 1
• Ensure adequate analgesia and sedation 1
• Maintain normothermia or accept mild hypothermia from general anesthesia without aggressive rewarming 1
• Monitor serum osmolarity when using osmotic agents, as mannitol can cause renal failure, volume depletion, and rebound intracranial hypertension 1

Surgical Intervention

Perform immediate surgical evacuation for cerebellar hemorrhage with neurological deterioration, brainstem compression, hydrocephalus, or cerebellar ICH volume ≥15 mL. 1, 3, 2

• For cerebellar hemorrhage >3 cm diameter with brainstem compression or hydrocephalus, surgical evacuation provides good outcomes compared to poor medical outcomes 4
• Ventricular catheter alone is insufficient for cerebellar hemorrhage with compressed cisterns 4
• For supratentorial ICH, surgery remains uncertain for most patients (Class IIb evidence), though consider early surgery for patients with GCS 9-12 1, 3
• Patients with lobar hematomas extending to within 1 cm of cortical surface showed trend toward better outcomes with surgery within 96 hours 4, 3
• Consider decompressive craniectomy for patients with high ICP and mass effect 1
• Minimally invasive clot removal techniques may improve outcomes in lobar ICH and deserve further evaluation 5, 6

Intraventricular Hemorrhage Management

For intraventricular hemorrhage with hydrocephalus, use external ventricular drainage, potentially combined with intraventricular fibrinolysis. 7

• Intraventricular rt-PA administration appears to have fairly low complication rate but remains investigational (Class IIb evidence) 4
• Consider additional lumbar drainage in selected cases 7

Prevention of Secondary Complications

Apply intermittent pneumatic compression immediately upon admission for venous thromboembolism prophylaxis in immobile patients. 1, 2

• Initiate pharmacological thromboprophylaxis within 24 hours after bleeding has stabilized 1, 3
• Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk 2
• Monitor and aggressively manage fever, as hyperthermia may be detrimental 1
• Treat clinical seizures with antiseizure medications 2
• Administer antiseizure drugs for patients with electrographic seizures on EEG and altered mental status 2
• Monitor and manage glucose levels, avoiding both hyperglycemia and hypoglycemia 2
• Monitor for pneumonia, cardiac events, and acute kidney injury 1

Fluid and Electrolyte Management

Use 0.9% normal saline as the crystalloid of choice to prevent worsening cerebral edema. 1

• Maintain isotonicity and normoglycemia 1
• Monitor fluid and electrolyte balance, particularly sodium and potassium, as imbalances can lead to encephalopathy or cardiac complications 1
• Monitor renal function when using osmotic agents 1

Prognostication and Goals of Care

Avoid early do-not-resuscitate orders or withdrawal of active care in the first 24-48 hours, as early prognostication is difficult. 5, 8

• Use formal prognostic tools to offer information to patients and families rather than clinical gestalt alone 8
• Recognize that most patients present with small ICHs that are readily survivable with good medical care 4, 3
• Hematoma volume and GCS score on admission are the most powerful predictors of 30-day mortality 3

Critical Pitfalls to Avoid

• Delaying neuroimaging: Hematoma expansion commonly occurs within the first few hours, and delayed imaging misses opportunities for intervention 2
• Failing to rapidly correct coagulopathy: Continued anticoagulation leads to hematoma expansion and worse outcomes 2, 5
• Premature prognostication: Withdrawing care too early in the first 24-48 hours may deny patients with potential for meaningful recovery 5, 8
• Overlooking secondary causes: Vascular malformations, tumors, or cerebral vein thrombosis may present as ICH in atypical locations or patient populations 2
• Using ventricular catheter alone for cerebellar hemorrhage: This is insufficient, especially with compressed cisterns; surgical evacuation is required 4

Long-term Management

Control blood pressure long-term in all ICH patients to prevent recurrence. 2

• Provide access to multidisciplinary rehabilitation services for all ICH patients 2
• Implement physical therapy and acute rehabilitation after hemorrhage stabilization 8