What is the management approach for intracerebral hemorrhage (ICH)?

Management of Intracerebral Hemorrhage (ICH)

Immediate Emergency Actions

All ICH patients must be admitted to an intensive care unit or dedicated stroke unit with neuroscience expertise, as this reduces mortality. 1, 2

Diagnostic Imaging

• Obtain immediate non-contrast CT scan to confirm diagnosis—this is mandatory and takes priority over all other tests 2, 3, 4
• CT is the gold standard for identifying acute hemorrhage 2
• Consider CT angiography to identify patients at risk for hematoma expansion 2
• Perform baseline Glasgow Coma Scale (GCS) or NIH Stroke Scale assessment 2, 3

Blood Pressure Management

For patients with systolic BP 150-220 mmHg, immediately lower systolic BP to <140 mmHg—this is safe and improves functional outcomes. 1, 2, 3

• Begin BP control within 6 hours of ICH onset 1
• Use nicardipine as first-line agent (superior to labetalol with faster response time) 3
• Monitor BP every 15 minutes until stabilized 3
• Avoid BP reductions ≥60 mmHg within 1 hour 5
• Maintain sustained control with minimal variability during first 24 hours 5

The INTERACT2 trial demonstrated that intensive BP lowering to <140 mmHg results in modestly better functional recovery, though only one-third of patients achieved target within 1 hour 1. This recommendation applies to patients similar to those enrolled in INTERACT2 (mostly mild-to-moderate ICH <20 mL) 1.

Reversal of Coagulopathy

For warfarin-associated ICH with elevated INR, immediately administer prothrombin complex concentrate (PCC) plus intravenous vitamin K—this is superior to fresh frozen plasma. 2, 3, 4

Specific Reversal Agents:

• Warfarin: Four-factor PCC plus vitamin K 2, 4, 5
• Dabigatran: Idarucizumab; if unavailable, consider hemodialysis 4, 5
• Factor Xa inhibitors (rivaroxaban, apixaban): Four-factor PCC (50 U/kg) or activated PCC (50 U/kg), or andexanet alfa where available 4, 5
• Heparin: Protamine sulfate at 1 mg per 100 units of heparin given in previous 2-3 hours (maximum 50 mg single dose) 4
• Severe thrombocytopenia: Platelet transfusion 2

Note: There is no evidence for routine platelet transfusion in patients taking aspirin or clopidogrel 6.

Prevention of Hematoma Expansion

Do NOT use recombinant factor VIIa or other hemostatic therapy for acute ICH not associated with anticoagulant use—it reduces hematoma expansion but does not improve outcomes and increases thromboembolic complications. 2, 5, 6

Hematoma expansion occurs in approximately 20-40% of patients within the first few hours and is associated with clinical deterioration and increased mortality 3, 4.

Intracranial Pressure Management

Monitoring Indications:

• GCS ≤8 2, 4
• Clinical evidence of transtentorial herniation 2, 4
• Significant intraventricular hemorrhage or hydrocephalus 2, 4

ICP Treatment Measures:

• Elevate head of bed 20-30 degrees 3, 4
• Maintain cerebral perfusion pressure 50-70 mmHg 2
• Place ventricular catheter for CSF drainage in patients with decreased consciousness due to hydrocephalus 2
• Consider osmotherapy with mannitol 0.25-0.5 g/kg IV every 6 hours (maximum 2 g/kg) for deteriorating patients 3
• Treat exacerbating factors: hypoxia, hypercarbia, hyperthermia 3, 4
• Avoid hypotonic fluids; use 0.9% saline as crystalloid solution 4

Surgical Management

Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus must undergo surgical removal as soon as possible. 1, 2, 3, 4

Additional Surgical Considerations:

• Consider early surgery for supratentorial ICH with GCS 9-12 1, 2
• Superficial lobar hemorrhages within 1 cm of cortical surface may benefit from evacuation 2, 4
• Obtain prompt neurosurgical consultation for all ICH patients 3
• Minimally invasive procedures for hematoma removal show potential for improving outcomes in lobar ICH 7
• Intraventricular hemorrhage can be treated with external ventricular drainage and intraventricular fibrinolysis 7

Meta-analyses report increased likelihood of good functional outcome with surgery compared to medical treatment alone, though no single large phase III trial has shown overall benefit 5.

Prevention of Secondary Complications

Venous Thromboembolism Prophylaxis:

Use intermittent pneumatic compression beginning on day of admission—do NOT use graduated compression stockings as they provide no benefit and may cause harm. 1, 2, 3

Seizure Management:

• Treat clinical seizures with antiseizure medications 2
• Treat electrographic seizures on EEG with altered mental status 2
• Do NOT use prophylactic antiseizure drugs routinely—they are associated with increased death and disability 1
• Cortical involvement is the most important risk factor for early seizures 1

Other Preventive Measures:

• Perform formal dysphagia screening before oral intake to reduce pneumonia risk 2, 3
• Monitor and manage glucose levels, avoiding both hyperglycemia and hypoglycemia 2
• Continuous cardiopulmonary monitoring including automated BP cuff, ECG telemetry, and pulse oximetry 1
• Consider continuous intra-arterial BP monitoring for patients receiving IV vasoactive medications 1

Interventions to AVOID

Never administer corticosteroids for ICH—they provide no benefit and may cause harm. 1, 2

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, 4

• Treated hypertension reduces ICH risk (OR 1.4) compared to untreated hypertension (OR 3.5) 2, 4
• Strongly discourage smoking, heavy alcohol use, and cocaine use 2, 4

Rehabilitation

All ICH patients should have access to multidisciplinary rehabilitation services beginning as early as possible. 2

Critical Pitfalls

• Early deterioration is common: Over 20% of patients experience GCS decrease of ≥2 points between prehospital assessment and ED evaluation 3, 4
• Avoid premature prognostication: Early do-not-resuscitate orders or withdrawal of care should be used judiciously in the first 24-48 hours 5
• Do not delay imaging or treatment while waiting for diagnostic test results 3
• Failing to rapidly correct coagulopathy leads to continued hematoma expansion and worse outcomes 2
• Overlooking secondary causes (vascular malformations, tumors, cerebral venous thrombosis) in atypical presentations 2