What is the management approach for a patient with intracranial hemorrhage (ICH) identified on a computed tomography (CT) scan?

Management of Intracranial Hemorrhage on CT Scan

When blood is identified on a CT scan, this is a medical emergency requiring immediate aggressive management focused on preventing hematoma expansion, correcting coagulopathy, and monitoring for neurological deterioration—all of which directly impact mortality and morbidity. 1

Immediate Initial Actions

Neuroimaging Confirmation and Risk Stratification

• Obtain rapid non-contrast CT scan as the gold standard for confirming acute intracranial hemorrhage, with 100% sensitivity from the moment of formation 1, 2
• Perform baseline severity assessment using Glasgow Coma Scale (GCS) immediately, as GCS and hematoma volume are the most powerful predictors of 30-day mortality 1
• Consider CT angiography (CTA) within the first 3 hours if the patient presents early, as 28-38% of patients scanned within 3 hours will have hematoma expansion of >33% on follow-up imaging 1
• CTA can identify contrast extravasation ("spot sign") within the hematoma, which predicts active bleeding and high risk of expansion 1, 2

Critical Monitoring Protocol

• Obtain follow-up CT at 6 and 24 hours in neurologically stable patients to detect hematoma expansion, which occurs in 26% within the first hour and an additional 12% by 20 hours 2
• Hematoma expansion is associated with a nearly 5-fold increase in clinical deterioration, poor outcome, and death 1

Coagulopathy Reversal (If Present)

For Warfarin/Vitamin K Antagonist (VKA) Users

• Rapidly correct INR as quickly as possible using prothrombin complex concentrates (PCCs) as first-line therapy 1
• Administer intravenous vitamin K 5-10 mg slowly as adjunct therapy (onset begins at 2 hours, maximal effect at 24 hours) 1
• Fresh frozen plasma (FFP) is less preferred due to need for thawing, cross-matching, large volumes required, and risk of transfusion reactions 1
• Recombinant factor VIIa (rFVIIa) and activated PCC (FEIBA) are alternative options 1

For Other Coagulopathies

• Replace specific coagulation factors for patients with congenital or acquired factor deficiencies 1
• Administer platelets for thrombocytopenia or qualitative platelet abnormalities 1

Evaluation for Secondary Causes

When to Suspect Underlying Structural Lesions

Obtain CTA, CT venography, MRI/MRA/MRV, or catheter angiography if any of the following are present 1:

• Patient factors: Age <55-65 years, female sex, nonsmoker, lobar ICH location, no history of hypertension 1
• Clinical features: Prodrome of headache, neurologic or constitutional symptoms before hemorrhage 1
• Radiologic red flags:
  • Subarachnoid hemorrhage component 1
  • Unusual (non-circular) hematoma shape 1
  • Edema disproportionate to hemorrhage timing 1
  • Unusual hemorrhage location 1
  • Enlarged vessels or calcifications along hematoma margins 1
  • Hyperattenuation in dural venous sinus or cortical vein 1
  • Presence of mass or other abnormal brain structures 1

Specific Vascular Imaging

• Perform MR or CT venography if cerebral vein thrombosis is suspected based on hemorrhage location, relative edema volume, or abnormal signal in cerebral sinuses 1
• CTA is highly sensitive and specific for detecting arteriovenous malformations, aneurysms, moyamoya, and tumors 1
• Consider catheter angiography if clinical suspicion remains high despite negative non-invasive studies 1

Critical Management Pitfalls to Avoid

• Do not delay imaging or reversal of coagulopathy: Active bleeding can proceed for hours after symptom onset, and two-thirds of hematoma expansion occurs within the first hour 1
• Do not rely on clinical features alone: It is impossible to distinguish ischemic stroke from hemorrhagic stroke based on clinical presentation; neuroimaging is mandatory 1, 3
• Do not miss anticoagulated patients: 12-14% of ICH patients are on oral anticoagulants, and this proportion is increasing—always obtain medication history 1
• Do not use vitamin K alone: Intravenous vitamin K is insufficient for reversal in the first hours and must be combined with PCCs or FFP 1
• Do not skip follow-up imaging in anticoagulated patients: Even if initial CT is negative, obtain 24-hour follow-up CT due to 1.4-4.5% risk of late bleeding 2

Additional Considerations

Blood Pressure Management

• Elevated systolic blood pressure >220 mmHg on admission has been associated with hematoma growth in retrospective studies, though prospective validation is limited 1
• Monitor cardiovascular status closely, as mannitol and other interventions may worsen congestive heart failure 4

Fever Monitoring

• Fever >37.5°C persisting for 24 hours occurs in 83% of patients with poor outcomes and correlates with ventricular extension 1

Elevated Troponin

• Elevated troponin levels are associated with worse outcomes and may indicate concomitant myocardial injury 1