From the Guidelines
Acute treatment priorities in intracerebral hemorrhage (ICH) patients should focus on stabilizing the patient, preventing hematoma expansion, managing intracranial pressure, and addressing underlying causes, 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 1.
Key Interventions
- Initial management includes securing the airway, maintaining adequate oxygenation (target SpO2 >94%), and ensuring hemodynamic stability.
- Blood pressure control is critical, with a target systolic blood pressure of 130-140 mmHg using titratable IV agents like nicardipine, labetalol, or clevidipine.
- Reversal of anticoagulation should be immediate: for warfarin, administer 4-factor prothrombin complex concentrate with vitamin K 10 mg IV; for direct oral anticoagulants, specific reversal agents include idarucizumab for dabigatran and andexanet alfa for factor Xa inhibitors 1.
- Seizure prophylaxis is not routinely recommended but seizures should be treated promptly with levetiracetam or other antiepileptics.
- Elevated intracranial pressure requires head elevation to 30 degrees, osmotic therapy with mannitol or hypertonic saline, and possible external ventricular drainage for hydrocephalus.
Neurosurgical Evaluation
- Neurosurgical evaluation is essential for large hematomas, cerebellar hemorrhages >3 cm, or deteriorating neurological status.
- Minimally invasive approaches for evacuation of supratentorial ICHs and intraventricular hemorrhages, compared with medical management alone, have demonstrated reductions in mortality 1.
Rehabilitation and Recovery
- Rehabilitation and recovery are important determinants of ICH outcome and quality of life.
- Coordinated multidisciplinary care with early assessment of discharge planning and a goal of early supported discharge for mild to moderate ICH is recommended 1.
From the Research
Acute Treatment Priorities in ICH Patients
The main priorities in the acute treatment of intracerebral hemorrhage (ICH) patients include:
- Blood pressure management to minimize ongoing bleeding while maximizing cerebral perfusion 2, 3, 4
- Coagulopathy reversal, particularly in patients receiving oral anticoagulation therapy 2, 5, 6
- Intracranial pressure control to prevent further brain damage 2, 3, 4
- Prevention of hematoma expansion and consideration of minimally invasive hematoma evacuation as therapeutic strategies 2
- Airway management, glucose management, and temperature management to provide supportive care 3
- Selected patients may benefit from external ventricular drainage or hematoma evacuation 3
Specific Considerations for Anticoagulated Patients
For patients with ICH who are receiving oral anticoagulation therapy:
- Rapid restoration of effective coagulation is a key target for treatment 6
- Reversal agents such as prothrombin complex concentrate, fresh frozen plasma, and recombinant activated factor VII may be used for anticoagulation reversal in patients receiving vitamin K antagonists 5, 6
- In the absence of specific antidotes, prothrombin complex concentrates are recommended for reversal of new direct oral anticoagulants (NOACs) 6