How to manage a patient with an intraparenchymal hemorrhage (IPH) who may be on anticoagulants?

Management of Intraparenchymal Hemorrhage

Immediately discontinue all anticoagulants and antiplatelet agents, aggressively lower systolic blood pressure to 140 mmHg (avoiding <110 mmHg), reverse any coagulopathy with specific agents, and consider neurosurgical consultation for patients with significant mass effect or intraventricular extension. 1

Initial Assessment and Stabilization

Rapid Diagnostic Evaluation

• Obtain non-contrast head CT immediately to confirm diagnosis, measure hematoma volume, and assess for intraventricular extension or hydrocephalus 1
• Perform CT angiography (CTA) in patients <70 years with lobar hemorrhage, <45 years with deep/posterior fossa hemorrhage, or any patient without hypertension history to exclude vascular malformations 1
• Check coagulation studies (PT/INR, aPTT) immediately in all patients to guide reversal therapy 1
• Obtain baseline hemoglobin, platelet count, and assess for thrombocytopenia, uremia, or liver disease that may contribute to bleeding 1

Critical Site Recognition

• Intraparenchymal hemorrhage is classified as a critical site bleed with consequences including stupor, coma, permanent neurological deficit, and death 1
• Initial signs include unusually intense headache, emesis, reduced consciousness, vision changes, numbness, weakness, aphasia, ataxia, vertigo, or seizures 1

Blood Pressure Management

Aggressive BP Lowering Protocol

• Target systolic blood pressure of 140 mmHg within 6 hours of symptom onset to reduce hematoma expansion risk 1, 2
• Strictly avoid systolic BP <110 mmHg, as this may compromise cerebral perfusion 1
• Use IV beta blockers (labetalol) or calcium channel blockers (nicardipine) for rapid, titratable control 2
• Maintain continuous invasive arterial pressure monitoring if mean arterial pressure <65 mmHg or hemodynamic instability present 1

Cerebral Perfusion Pressure Management

• Monitor intracranial pressure (ICP) in patients with Glasgow Coma Scale ≤8, clinical transtentorial herniation, or significant intraventricular hemorrhage with hydrocephalus 1
• Maintain cerebral perfusion pressure between 50-70 mmHg 1

Anticoagulation Reversal

Vitamin K Antagonist (Warfarin) Reversal

• Administer 4-factor prothrombin complex concentrate (4F-PCC) immediately for INR ≥2.0, preferred over fresh frozen plasma 1
• Give IV vitamin K 5-10 mg shortly after PCC to prevent re-emergence of anticoagulation 1
• Use 3F-PCC or fresh frozen plasma only when 4F-PCC unavailable 1

Direct Oral Anticoagulant (DOAC) Reversal

• Administer idarucizumab for dabigatran-associated hemorrhage 1, 3
• Give andexanet alfa for apixaban or rivaroxaban-associated hemorrhage; if unavailable, use 4F-PCC 1, 3
• Do not routinely administer reversal agents for non-major bleeding without hemodynamic instability 4

Heparin Reversal

• Administer protamine sulfate for heparin-related intracerebral hemorrhage 1

Antiplatelet Therapy Management

Critical Pitfall

• Do NOT transfuse platelets in patients on antiplatelet therapy—recent trials demonstrate no benefit and potential harm 2, 5
• Stop all antiplatelet agents immediately 1
• Prothrombin complex concentrates, vitamin K, idarucizumab, and andexanet alfa are exclusively for anticoagulant reversal, NOT antiplatelet therapy 3, 6

Neurosurgical Considerations

Indications for Surgical Intervention

• External ventricular drainage is recommended for intraventricular hemorrhage with hydrocephalus causing decreased consciousness 1
• Consider stereotactically guided hematoma evacuation for patients with intraventricular extension—shown to be safe and improve outcomes 2
• Evaluate for decompressive surgery in patients with significant mass effect and deteriorating neurological status 1

Surgical Timing Considerations

• Surgical hematoma evacuation under ongoing anticoagulation has extremely high rates of recurrent hemorrhage (75%) and mortality (75%) 7
• Postponing anticoagulation after surgery may improve clinical outcomes and survival 7

Intensive Care Management

Admission and Monitoring

• Admit to dedicated neurologic ICU or stroke unit for continuous monitoring 1
• Perform cardiac monitoring for at least 24 hours to screen for atrial fibrillation and arrhythmias 1
• Monitor for seizures—antiseizure medications only indicated for documented secondary seizures, not prophylaxis 1

Supportive Care

• Provide volume resuscitation with isotonic crystalloids if hemodynamically unstable 1, 4
• Transfuse packed red blood cells to maintain hemoglobin ≥7 g/dL (≥8 g/dL if coronary artery disease present) 4
• Monitor body temperature and treat fever >38°C; investigate and treat infection sources 1
• Serial hemoglobin measurements to assess ongoing blood loss 4

Complications Management

Hydrocephalus

• Hydrocephalus occurs in 23% of all ICH patients and 55% of those with intraventricular hemorrhage 1
• Hydrocephalus predicts poor outcome and requires treatment in patients with decreased consciousness 1
• Ventricular catheter allows both ICP monitoring and CSF drainage 1

Intracranial Pressure Monitoring

• Consider ICP monitoring in patients with GCS ≤8, clinical transtentorial herniation, or significant intraventricular hemorrhage 1
• Ventricular catheter preferred over parenchymal catheter when hydrocephalus present, despite slightly higher infection risk (4% vs 2.9%) 1
• Correct coagulopathy before ICP monitor insertion; consider platelet transfusion if prior antiplatelet use 1

Restarting Anticoagulation

Decision Algorithm

• Restart anticoagulation only if bleeding source identified and treated, patient has high thrombotic risk, and adequate time has elapsed for hemorrhage stabilization 3
• Delay or discontinue anticoagulation if bleeding occurred in critical site, high rebleeding risk, or source not identified 3
• Carefully reassess indication for anticoagulation given the critical nature of intracranial hemorrhage 4, 3

Common Pitfalls to Avoid

• Do not assume hemoglobin stability rules out ongoing bleeding—pre-resuscitation hemoglobin may be artificially elevated from hemoconcentration 1
• Do not delay imaging or intervention waiting for "more obvious" signs—any hemoglobin drop ≥2 g/dL represents major bleeding with significantly increased mortality risk 1
• Do not use ABC/2 method for volume estimation in warfarin-related hemorrhage—it underestimates larger, complex-shaped, multicompartmental hematomas by up to 28% 8
• Do not transfuse platelets for antiplatelet-associated hemorrhage—no proven benefit and potential harm 2, 5