What are the management and treatment options for a hemorrhagic intracerebral (IC) bleed?

Management of Hemorrhagic Intracerebral Bleed

Immediate Emergency Department Actions

All patients with suspected ICH require immediate non-contrast CT imaging to confirm diagnosis and distinguish from ischemic stroke, followed by admission to an intensive care unit or dedicated stroke unit with neuroscience expertise. 1, 2

Initial Assessment

• Obtain baseline Glasgow Coma Scale or NIH Stroke Scale score immediately upon presentation 1
• Consider CT angiography to identify patients at risk for hematoma expansion 1
• Evaluate coagulation status urgently (INR, platelet count, anticoagulant history) 1

Blood Pressure Management

For patients presenting with systolic BP 150-220 mmHg, immediately lower systolic BP to <140 mmHg within 6 hours of onset—this is safe and improves functional outcomes. 1, 3

• Begin BP control measures immediately after ICH diagnosis 1
• Target systolic BP <140-160 mmHg to prevent hematoma expansion 3
• Avoid medications causing cerebral vasodilation or increased cerebral blood volume (these worsen intracranial compliance and precipitate herniation) 3

Coagulopathy Reversal

Rapidly correct any coagulopathy within the first hours—delays lead to continued hematoma expansion and worse outcomes. 1

For Warfarin/Vitamin K Antagonists:

• Immediately withhold the anticoagulant 1
• Administer prothrombin complex concentrates (PCCs)—preferred over fresh frozen plasma for rapid INR correction 1
• Give intravenous vitamin K 1

For Direct Oral Anticoagulants:

• Idarucizumab for dabigatran 3
• Andexanet alfa for factor Xa inhibitors 3

For Thrombocytopenia/Platelet Dysfunction:

• Administer platelets for severe thrombocytopenia 1
• Replace appropriate clotting factors for severe coagulation factor deficiency 1

Intracranial Pressure Management

Monitor ICP in patients with Glasgow Coma Scale ≤8, clinical evidence of transtentorial herniation, significant intraventricular hemorrhage, or hydrocephalus. 2, 3

ICP Treatment Strategy:

• Maintain cerebral perfusion pressure 50-70 mmHg depending on autoregulation status 2
• Use osmotic agents (mannitol 0.25-1.0 gm/kg bolus or hypertonic saline 23.4% 30cc bolus) to achieve hyperosmolality and euvolemia 3, 4
• Perform CSF drainage via external ventricular drainage for hydrocephalus or ventricular obstruction 3
• Hyperventilation initially, but rapidly transition to CSF drainage and osmotic therapy 4

Ventricular Drainage:

Place ventricular catheter for CSF drainage in patients with decreased level of consciousness due to hydrocephalus. 2

Surgical Indications

Cerebellar Hemorrhage (URGENT):

Patients with cerebellar hemorrhage >3 cm with neurological deterioration, brainstem compression, or hydrocephalus require immediate surgical evacuation—do not delay with ventricular catheter alone. 2, 1

Supratentorial Hemorrhage:

• Consider early surgery for patients with Glasgow Coma Scale 9-12 2
• Superficial lobar hemorrhages (within 1 cm of cortical surface) may benefit from evacuation 2

Prevention of Secondary Complications

Venous Thromboembolism:

• Begin intermittent pneumatic compression on day of admission 1
• Avoid graduated compression stockings (evidence shows no benefit and potential harm) 2

Seizure Management:

• Treat clinical seizures with antiseizure medications 1
• Treat electrographic seizures on EEG with altered mental status 1
• Do not use prophylactic antiepileptic drugs (no benefit demonstrated) 5

Metabolic Management:

• Use 0.9% saline as crystalloid of choice to prevent worsening cerebral edema 3
• Monitor and manage glucose levels, avoiding both hyperglycemia and hypoglycemia 1
• Avoid hypoxia and hypercarbia (both increase cerebral blood volume and worsen ICP) 4

Aspiration Prevention:

• Perform formal dysphagia screening before initiating oral intake 1

Contraindicated Interventions

Never administer corticosteroids for ICH—they provide no benefit and may cause harm. 2, 3

Avoid hemostatic therapy (such as recombinant factor VIIa) for acute ICH not associated with antithrombotic drug use—it reduces hematoma expansion but does not improve outcomes and increases thromboembolic complications. 2, 5

Rehabilitation

All ICH patients should have access to multidisciplinary rehabilitation beginning as early as possible, ideally with coordinated transition to community-based programs. 2, 1

Long-Term Secondary Prevention

Control blood pressure long-term in all ICH survivors—this is the single most important modifiable risk factor for recurrence. 2, 1

• Treated hypertension reduces ICH risk (OR 1.4) compared to untreated hypertension (OR 3.5) 2
• Strongly discourage smoking, heavy alcohol use, and cocaine use 2

Critical Pitfalls to Avoid

• Delaying neuroimaging: Hematoma expansion occurs within the first hours—every minute counts 1
• Inadequate coagulopathy reversal: Use PCCs, not fresh frozen plasma, for warfarin reversal 1
• Using ventricular catheter alone for cerebellar hemorrhage: This is insufficient—immediate surgical evacuation is required 2
• Missing secondary causes: Look for vascular malformations, tumors, or cerebral venous thrombosis in atypical presentations or unusual hemorrhage locations 1
• Aggressive BP lowering without context: While intensive BP reduction is appropriate for ICH, avoid this in ischemic stroke without thrombolysis 6