What is the management and treatment approach for a patient with intracerebral hemorrhage?

Management of Intracerebral Hemorrhage

Intracerebral hemorrhage is a medical emergency requiring immediate CT imaging, rapid blood pressure reduction to systolic <140 mmHg (if presenting between 150-220 mmHg), urgent reversal of any coagulopathy, and admission to a neuroscience intensive care unit or stroke unit. 1

Prehospital and Emergency Response

• Activate emergency medical services (9-1-1) immediately upon recognition of stroke symptoms to minimize time to diagnosis and treatment 1
• EMS personnel should use stroke recognition tools to identify potential ICH and provide advance notification to the receiving hospital, which significantly shortens time to CT scanning 1
• Primary objectives include airway management, cardiovascular support, and transport to the closest facility with neurology, neuroradiology, neurosurgery, and critical care capabilities 1
• Obtain focused history regarding symptom onset timing, medications (especially anticoagulants and antiplatelets), vascular risk factors, recent trauma, and drug use 1

Immediate Diagnostic Evaluation

Rapid neuroimaging with non-contrast CT is mandatory and considered the gold standard for distinguishing ICH from ischemic stroke—MRI with gradient echo sequences is equally sensitive but often impractical 1, 2

Essential Initial Workup

• Perform baseline severity score (Glasgow Coma Scale or ICH Score) as part of initial evaluation to streamline assessment and communication between providers 1
• Complete blood count, electrolytes, renal function, glucose, cardiac troponin 1
• Prothrombin time with INR and activated partial thromboplastin time to identify coagulopathy 1
• Toxicology screen for cocaine and sympathomimetic drugs 1
• ECG and continuous cardiopulmonary monitoring including automated blood pressure, telemetry, and pulse oximetry 2
• Consider CT angiography to identify patients at high risk for hematoma expansion (contrast extravasation predicts expansion) 1, 2

Acute Blood Pressure Management

For patients with systolic BP 150-220 mmHg without contraindications, immediately lower systolic BP to <140 mmHg within 6 hours—this is safe and improves functional outcomes 1, 2, 3

• Begin BP control measures immediately after ICH onset 1
• Avoid BP reductions ≥60 mmHg within 1 hour, as careful and sustained treatment optimizes outcomes 3
• Target systolic BP as low as 120-130 mmHg while minimizing variability during the first 24 hours 3

Reversal of Coagulopathy

Vitamin K Antagonist (Warfarin)-Related ICH

Patients with elevated INR from warfarin must have the anticoagulant withheld, receive therapy to replace vitamin K-dependent factors, correct the INR, and receive intravenous vitamin K 1

• Prothrombin complex concentrates (PCC) are strongly preferred over fresh frozen plasma for rapid INR correction 2, 4, 3
• The need to arrest intracranial bleeding outweighs all other considerations in warfarin-related ICH 4

Direct Oral Anticoagulant (DOAC)-Related ICH

• Dabigatran: Use idarucizumab for reversal 5, 3
• Factor Xa inhibitors (rivaroxaban, apixaban, edoxaban): Use andexanet alfa where available, or PCC as alternative 5, 3
• Rapid reversal reduces hematoma expansion risk and may improve outcomes 3

Thrombocytopenia and Coagulation Factor Deficiency

• Patients with severe thrombocytopenia should receive platelets 1
• Patients with severe coagulation factor deficiency should receive appropriate factor replacement therapy 1

Hospital Care Setting

All ICH patients require admission to a neuroscience intensive care unit or dedicated stroke unit with physician and nursing neuroscience expertise—this reduces mortality 1, 2

• Prolonged ED stays worsen outcomes; initiate time-sensitive treatments (BP lowering, coagulopathy reversal) in the ED rather than waiting for ICU transfer 1
• Regional systems of stroke care should ensure all patients have access to neurocritical care and neurosurgical capabilities 1

Intracranial Pressure Management

ICP monitoring should be considered in patients with Glasgow Coma Scale ≤8, hydrocephalus, or clinical evidence of transtentorial herniation 5, 2

• Maintain cerebral perfusion pressure 50-70 mmHg depending on autoregulation status 2
• Use osmotic agents (mannitol or hypertonic saline) to produce hyperosmolality and euvolemia in patients with elevated ICP 5, 6
• Mannitol dosing for intracranial pressure reduction: Adults 0.25-2 g/kg as 15-25% solution over 30-60 minutes; Pediatrics 1-2 g/kg over 30-60 minutes 6
• Place external ventricular drain for CSF drainage in patients with decreased consciousness due to hydrocephalus or ventricular obstruction 5, 2

Surgical Management

Cerebellar Hemorrhage

Patients with cerebellar hemorrhage >3 cm who are deteriorating neurologically or have brainstem compression and/or hydrocephalus require surgical removal as soon as possible—do not delay with ventricular catheter alone 1, 2, 3

Supratentorial ICH

• Consider early surgery for patients with Glasgow Coma Scale 9-12 5, 2
• Superficial lobar hemorrhages within 1 cm of cortical surface may benefit from evacuation 2
• Meta-analyses report increased likelihood of good functional outcome with surgery compared to medical treatment only, though no single large phase III trial has shown overall benefit 3

Prevention of Secondary Complications

Venous Thromboembolism Prophylaxis

Begin intermittent pneumatic compression on the day of hospital admission for prevention of venous thromboembolism 1, 2

• Do NOT use graduated compression stockings—they provide no benefit and may cause harm 2

Seizure Management

• Treat clinical seizures with antiseizure medications 2
• Patients with electrographic seizures on EEG and altered mental status should receive antiseizure drugs 2
• Do NOT use prophylactic antiseizure drugs routinely—they are associated with increased death and disability 2

Aspiration Prevention

• Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk 2

Fluid Management

• Use 0.9% saline as the crystalloid of choice to prevent worsening cerebral edema 5
• Monitor and manage glucose levels, avoiding both hyperglycemia and hypoglycemia 2

Contraindicated Interventions

Never administer corticosteroids (dexamethasone or other glucocorticoids) for ICH—they provide no benefit and may cause harm 5, 2, 7

• Avoid medications that cause cerebral vasodilation or increase cerebral blood volume in acute ICH, as these worsen intracranial compliance and can precipitate herniation 5
• Do NOT use hemostatic therapy (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, 4
• Avoid acetazolamide in ICH management 5

Monitoring and Ongoing Management

• Discontinue mannitol if renal, cardiac, or pulmonary status worsens, or CNS toxicity develops 6
• Avoid concomitant administration of nephrotoxic drugs or other diuretics with mannitol due to increased risk of renal failure 6
• More than 20% of patients experience GCS decrease of ≥2 points between prehospital assessment and ED arrival, with another 15-23% deteriorating within first hours after hospital arrival 1
• Hematoma expansion occurs in 28-38% of patients imaged within 3 hours of onset and predicts clinical deterioration and worse outcomes 1

Rehabilitation

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

• 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

• Early prognostication is difficult—avoid early do-not-resuscitate orders or withdrawal of active care in the first 24-48 hours, as aggressive acute management can translate into improved outcomes 4, 3
• Delaying neuroimaging misses opportunities for intervention during the critical window when hematoma expansion commonly occurs 2
• Failing to rapidly correct coagulopathy in anticoagulated patients leads to continued hematoma expansion and worse outcomes 2
• Overlooking secondary causes (vascular malformations, tumors, cerebral venous thrombosis) in patients with atypical presentations or unusual hemorrhage locations 2
• Mannitol may increase cerebral blood flow and risk of postoperative bleeding in neurosurgical patients, and may worsen intracranial hypertension in children with generalized cerebral hyperemia during first 24-48 hours post-injury 5