From the Guidelines
Acute treatment priorities in intracerebral hemorrhage (ICH) patients should focus on stabilizing the patient, preventing hematoma expansion, and managing complications, with a primary recommendation of lowering systolic blood pressure to a target range of 130 to 140 mm Hg, as soon as possible, in patients presenting with acute ICH of mild to moderate severity and systolic blood pressure between 150 and 220 mm Hg, as evidenced by the 2022 guideline from the American Heart Association/American Stroke Association 1. Initial management includes:
- Securing the airway, maintaining adequate oxygenation, and ensuring hemodynamic stability
- Blood pressure control using intravenous agents like nicardipine, labetalol, or clevidipine
- Reversal of anticoagulation, if applicable, with specific reversal agents
- Seizure prophylaxis is not routinely recommended but seizures should be treated promptly
- Intracranial pressure monitoring and management for patients with GCS ≤8 or signs of herniation Early neurosurgical consultation is necessary to evaluate for potential hematoma evacuation, particularly for cerebellar hemorrhages >3 cm or those causing hydrocephalus. These interventions aim to limit secondary brain injury by preventing hematoma expansion, reducing mass effect, and minimizing complications that could worsen neurological outcomes, as supported by the most recent guidelines 1. Key considerations include:
- Close blood pressure monitoring and careful titration of blood pressure-lowering therapy to ensure continuous smooth and sustained control of blood pressure
- Avoiding acute lowering of systolic blood pressure to <130 mm Hg in patients presenting with ICH and elevated blood pressure, as it is potentially harmful
- Individualized blood pressure targets to optimize secondary stroke prevention after the first 24 hours following the onset of an ICH.
From the Research
Acute Treatment Priorities in ICH Patients
The acute treatment priorities in Intracerebral Hemorrhage (ICH) patients include:
- Correction of abnormal coagulopathies, as stated in 2 and 3
- Blood pressure reduction, as mentioned in 2, 3, 4, and 5
- Emergent treatment of intracranial hypertension, as discussed in 2 and 4
- Recognition of those in need of urgent surgical decompression, as noted in 2 and 3
- Prevention of hematoma expansion, as mentioned in 3, 4, and 6
- Minimally invasive hematoma evacuation, as discussed in 4 and 6
Importance of Specialized Care
Patients with ICH should be admitted to capable critical care units, with expertise in neurocritical care if available, as recommended in 2 and 3. Acute stroke unit care improves outcome after ICH, as stated in 5.
Ongoing Research and Management
Ongoing research seeks to define optimal blood pressure, glucose, and temperature targets, the role and type of surgery, and potential neuroprotective strategies, as mentioned in 3 and 6. Well-organized, multimodal therapy optimizing intracranial and systemic physiological variables improves outcome after ICH, as discussed in 3 and 5.