How do you investigate and manage a case of acute intracerebral hemorrhage in a patient with a history of hypertension, diabetes, or cerebrovascular disease, who may be taking anticoagulant medications such as warfarin?

Management of Acute Intracerebral Hemorrhage

For acute ICH, immediately target systolic blood pressure to 140 mmHg (range 130-150 mmHg) within 6 hours using IV nicardipine or labetalol, reverse any anticoagulation with specific agents (4-factor PCC for warfarin, idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors), obtain urgent neurosurgical consultation for cerebellar hemorrhage or hydrocephalus, and admit to a neurocritical care unit. 1

Immediate Diagnostic Workup

Neuroimaging

• Obtain non-contrast CT head immediately to confirm ICH, measure hematoma volume, identify intraventricular extension, and assess for hydrocephalus 1
• Perform CTA with venography in patients meeting these criteria: lobar ICH age <70 years, deep/posterior fossa ICH age <45 years, or deep/posterior fossa ICH age 45-70 without hypertension history to exclude vascular malformations 1
• Order catheter angiography if non-invasive imaging suggests vascular anomaly or if isolated intraventricular hemorrhage without parenchymal component is present 1

Laboratory Assessment

• Draw immediately: platelet count, PT/INR, PTT, complete blood count, comprehensive metabolic panel, and obtain detailed anticoagulant/antiplatelet medication history 1
• Do not wait for laboratory results to initiate reversal if anticoagulant use is suspected based on history and timing 1

Neurological Monitoring

• Assess using validated scale (Glasgow Coma Scale or Canadian Neurological Scale) at baseline, then hourly for first 24 hours 1
• Evaluate for signs of increased intracranial pressure: declining consciousness, pupillary changes, Cushing's triad 1

Blood Pressure Management

Target Parameters

• Achieve systolic BP 140 mmHg (acceptable range 130-150 mmHg) within 6 hours for patients presenting with SBP 150-220 mmHg 1, 2, 3
• Maintain cerebral perfusion pressure ≥60 mmHg at all times, especially if elevated ICP suspected 4, 2, 3
• Keep mean arterial pressure <130 mmHg 4, 2

Critical Safety Thresholds

• Never drop SBP by >70 mmHg within first hour, particularly in patients presenting with SBP ≥220 mmHg—this increases acute kidney injury risk and mortality 1, 2, 3
• Avoid SBP <130 mmHg, as this is associated with worse outcomes in large ICH 2
• Strictly avoid SBP <110 mmHg at any time 1, 2

Monitoring Protocol

• Check BP every 15 minutes until stabilized, then every 30-60 minutes for first 24-48 hours 1, 2
• Use continuous arterial line monitoring in patients requiring aggressive BP control 3

Pharmacologic Approach

• First-line: IV nicardipine starting at 5 mg/h, increase by 2.5 mg/h every 5 minutes to maximum 15 mg/h—preferred for precise, titratable control 4, 2
• Alternative: IV labetalol 0.3-1.0 mg/kg slow IV push every 10 minutes OR 0.4-1.0 mg/kg/h continuous infusion up to 3 mg/kg/h 1, 4
• Avoid hydralazine due to unpredictable response and prolonged duration of action 4

Anticoagulation Reversal

Warfarin-Associated ICH

• Administer 4-factor PCC immediately for INR ≥2.0—this is superior to fresh-frozen plasma for rapid INR correction and limiting hematoma expansion 1
• Give IV vitamin K 10 mg directly after PCC to prevent later INR re-elevation 1
• Consider PCC for INR 1.3-1.9 to achieve rapid correction 1
• If 4-factor PCC unavailable, use fresh-frozen plasma or 3-factor PCC as alternatives 1

Direct Oral Anticoagulant-Associated ICH

• For dabigatran: administer idarucizumab 5 g IV (two 2.5 g doses) for immediate reversal 1
• For factor Xa inhibitors (rivaroxaban, apixaban, edoxaban): administer andexanet alfa 400-800 mg IV bolus followed by 480-960 mg infusion over 2 hours 1
• If specific reversal agents unavailable: use 4-factor PCC for factor Xa inhibitors 1
• Urgent hematology consultation for DOAC reversal guidance 1

Heparin-Associated ICH

• Administer protamine sulfate with dose based on time from heparin cessation 1

Antiplatelet-Associated ICH

• Stop all antiplatelet agents immediately (aspirin, clopidogrel, dipyridamole) 1
• Do not routinely give platelet transfusions unless patient requires urgent neurosurgery 1

Neurosurgical Consultation

Urgent Indications (Consult Immediately)

• Cerebellar hemorrhage with altered consciousness or brainstem signs—these patients require urgent surgical evaluation 1
• Acute hydrocephalus requiring external ventricular drain placement 1
• GCS 9-12 with supratentorial ICH—early surgical intervention may be considered in this select group 1
• Any consideration for decompressive craniectomy 1

General Surgical Principles

• Supratentorial ICH: surgical evacuation not superior to medical management for most patients—surgery reserved for select cases 1
• Hydrocephalus with decreased consciousness: external ventricular drainage recommended 1

Admission and Monitoring

Unit Selection

• Admit to neurocritical care unit or stroke unit with interprofessional team expertise 1
• All ICH patients require specialized stroke unit care for improved outcomes 1

Cardiac Monitoring

• Continuous cardiac monitoring for minimum 24 hours to screen for atrial fibrillation and arrhythmias 1

Intracranial Pressure Management

• Consider ICP monitoring in patients with multicompartmental hemorrhage and deteriorating neurological status to guide CPP-targeted therapy 2
• Osmotic therapy with mannitol for elevated ICP 5

Common Pitfalls to Avoid

• Delaying BP treatment beyond 2 hours: therapeutic window for preventing hematoma expansion is narrow—initiate treatment immediately 2, 3
• Excessive BP variability: peaks and fluctuations worsen outcomes independent of mean BP achieved—use smooth, continuous titration 2
• Waiting for INR results before reversing warfarin: initiate reversal based on history and timing of anticoagulant use 1
• Restarting anticoagulation too early: decision requires case-by-case assessment with stroke expert, cardiologist, and hematologist consultation—typical consideration at 7-10 days for high thromboembolism risk 1
• Aggressive mobilization within 24 hours: commence mobilization within 48 hours unless contraindicated, but avoid intensive out-of-bed activities in first 24 hours 1

Special Populations

Pontine/Midbrain Hemorrhage with Severe Hypertension

• For initial SBP ≥220 mmHg: reduce carefully to <180 mmHg as initial step, then gradually to 140-160 mmHg target within 6 hours 3
• Never exceed 70 mmHg drop in first hour even with extreme hypertension 3
• Maintain CPP ≥60 mmHg throughout given high risk of elevated ICP with posterior fossa hemorrhage 3