What is the initial treatment approach for a patient presenting with acute intracerebral hemorrhage?

Initial Treatment of Acute Intracerebral Hemorrhage

Treat acute intracerebral hemorrhage as a medical emergency requiring immediate ABC stabilization, urgent CT imaging, blood pressure reduction to 140 mmHg systolic (if presenting at 150-220 mmHg), rapid anticoagulation reversal if applicable, and admission to a neurocritical care or stroke unit with hourly neurological monitoring for the first 24 hours. 1, 2, 3

Immediate Emergency Assessment (First 15-30 Minutes)

Perform rapid ABC assessment (airway, breathing, circulation) immediately upon arrival—this takes absolute priority. 2, 3

• Conduct neurological examination using the National Institutes of Health Stroke Scale (NIHSS) to quantify stroke severity and focal deficits 2, 3
• Obtain immediate non-contrast CT scan to confirm diagnosis, location, and extent of hemorrhage—this is mandatory and takes priority over all other diagnostic tests 2, 3
• Draw urgent blood work including complete blood count, coagulation status (INR, aPTT), and glucose 2
• Obtain detailed medication history, specifically asking about anticoagulants and antiplatelet agents 2

Critical pitfall: Over 20% of patients deteriorate within the first few hours, experiencing a decrease in Glasgow Coma Scale of 2 or more points between prehospital assessment and initial ED evaluation. 2, 3 Do not delay imaging or treatment decisions while waiting for laboratory results. 2, 3

Blood Pressure Management (Initiate Within 2 Hours)

For patients presenting with systolic blood pressure 150-220 mmHg without contraindications, acutely lower systolic BP to 140 mmHg (target range 130-150 mmHg)—this is safe and improves functional outcomes. 1, 2, 4, 3

• Monitor blood pressure every 15 minutes until stabilized, then every 30-60 minutes for the first 24-48 hours 2, 4
• Use nicardipine as first-line agent—it is superior to labetalol for achieving and maintaining goal BP with faster response time and fewer treatment failures 2, 3
• Alternatively, use labetalol (0.3-1.0 mg/kg slow IV every 10 minutes or continuous infusion 0.4-1.0 mg/kg/h up to 3 mg/kg/h) 4
• Achieve target BP within 1 hour using continuous smooth titration to minimize blood pressure variability 4

Critical safety threshold: Avoid excessive blood pressure reduction—do not drop systolic BP by more than 70 mmHg within the first hour, particularly in patients presenting with systolic BP ≥220 mmHg, as this increases risk of acute renal injury and compromises cerebral perfusion. 4 Avoid systolic BP <130 mmHg in patients with large ICH, as this is associated with worse outcomes. 4

Avoid sodium nitroprusside in patients with markedly elevated intracranial pressure as it induces cerebral vasodilation. 2, 4

Reversal of Anticoagulation (Immediate Priority)

Warfarin/Vitamin K Antagonists

Patients on warfarin with elevated INR must receive prothrombin complex concentrate (PCC) plus intravenous vitamin K immediately—rapid reversal while limiting fluid volumes is critical. 1, 2, 3, 5

• Withhold warfarin immediately upon diagnosis 2, 3
• Administer PCC as first-line therapy (preferred over fresh-frozen plasma due to fast onset of action) 1
• Give intravenous vitamin K concurrently 1, 2
• Fresh-frozen plasma and vitamin K can be used as alternative if PCC is not available 1

Direct Oral Anticoagulants (DOACs)

Urgent consultation with hematologist is required regarding use and availability of reversal agents. 1

• For dabigatran (thrombin inhibitor): use idarucizumab 1, 5
• For factor Xa inhibitors (rivaroxaban, apixaban, edoxaban): use andexanet alfa where available, or PCC as alternative 1, 5

Antiplatelet Agents

Stop antiplatelet agents (ASA, clopidogrel, dipyridamole/ASA) immediately in patients who present on these medications. 1

Thrombocytopenia and Coagulation Factor Deficiency

• Patients with severe thrombocytopenia should receive platelet transfusion 2
• Patients with severe coagulation factor deficiency should receive appropriate factor replacement therapy 2

Monitoring and Care Setting

Initial monitoring and management must occur in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise. 1, 2, 3

• Perform validated neurological scale assessments at baseline and repeat at least hourly for the first 24 hours 1, 2, 3
• Maintain nurse-patient ratio of 1:2 for the first 24 hours, then 1:4 if patient condition is stable 2
• Monitor for hematoma expansion, which occurs in 30-40% of patients and is a predictor of poor outcome 2

Management of Increased Intracranial Pressure

Elevate head of bed 20-30 degrees to facilitate venous drainage. 2, 3

• Treat all factors that exacerbate raised intracranial pressure: hypoxia, hypercarbia, and hyperthermia 2, 3
• Consider osmotherapy with mannitol 0.25-0.5 g/kg IV over 20 minutes every 6 hours (maximum 2 g/kg) for patients deteriorating due to increased intracranial pressure 2, 3
• Hyperventilation can be used as a temporizing measure for patients with herniation syndromes 2
• Do not use corticosteroids for management of cerebral edema and increased intracranial pressure—they are not recommended 2

Maintain cerebral perfusion pressure at or above 60 mmHg at all times, especially if elevated intracranial pressure is present. 4 Consider ICP monitoring in patients with multicompartmental hemorrhage and deteriorating neurological status. 4

Neurosurgical Consultation and Surgical Considerations

Obtain prompt neurosurgical consultation for all ICH patients to evaluate potential surgical interventions. 1, 2, 3

Cerebellar Hemorrhage (Urgent Surgical Emergency)

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

Hydrocephalus

• Patients with new onset of acute hydrocephalus requiring placement of external ventricular drain (EVD) should be referred for urgent neurosurgical consultation 1
• External ventricular drainage with intraventricular fibrinolysis for intraventricular hemorrhage promotes hematoma clearance, decreases mortality, and improves functional outcomes 2

Supratentorial ICH

• Surgical intervention has not been shown to be superior to conservative management to improve outcomes in most patients with supratentorial ICH 1
• In select patients with higher level of consciousness (especially Glasgow Coma Scale score 9-12), early surgical intervention may be considered 1, 2
• Early consultation with neurosurgeon is recommended in cases where decompressive craniectomy is considered 1

Seizure Management

Treat new-onset seizures occurring within 24 hours of stroke onset with short-acting medications (e.g., lorazepam IV) if not self-limited. 2, 3

• Do not treat single, self-limiting seizures at onset or within 24 hours with long-term anticonvulsant medications 2, 3
• Recurrent seizures should be treated as with any other acute neurological condition 2
• Prophylactic anticonvulsants are not recommended for patients who have not had seizures 1, 2

Prevention of Complications

Venous Thromboembolism Prophylaxis

Implement intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission. 2, 3

• Do not use graduated compression stockings as they are less effective than intermittent pneumatic compression 2, 3
• Consider starting pharmacological VTE prophylaxis with unfractionated heparin or low-molecular-weight heparin after documenting hemorrhage stability on CT, typically 24-48 hours after ICH onset 2

Aspiration Prevention

Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk. 2, 3

Fluid Management

• Avoid hypo-osmolar fluids such as 5% dextrose in water as they may worsen cerebral edema 2
• Mild restriction of fluids is recommended to help manage brain edema 2

Additional Diagnostic Workup

In patients with confirmed acute ICH, vascular imaging (CT angiography, MR angiography, or catheter angiography) is recommended to exclude underlying lesions such as aneurysms or arteriovenous malformations. 2 This is particularly important in younger patients or those with atypical hemorrhage locations.

Goals of Care and Prognostication

For most patients, decisions related to DNR orders or palliative care should be deferred for 24 to 48 hours after stroke onset, to allow time to see if there is significant response to medical therapy or if there is worsening. 1

• Goals of care should be established with patient and/or designated substitute decision-maker 1
• Exceptions may include patients with preexisting wishes to avoid invasive life-sustaining therapies because of comorbidities or based on their own previously expressed values 1
• Patients who are given DNR status at any point should receive all other appropriate medical and surgical interventions unless otherwise explicitly indicated 1
• Early prognostication is difficult, and early do-not-resuscitate orders or withdrawal of active care should be used judiciously in the first 24-48 hours of care 5

Therapies NOT Recommended

Recombinant Factor VIIa (NiaStase) is not recommended for use outside of clinical trials—it prevents hematoma growth but increases the risk of arterial thromboembolic phenomena and does not provide clinical benefit for survival or outcome. 1