What is the immediate management of an adult with acute intracerebral hemorrhage, including rapid neuroimaging, blood pressure control, reversal of anticoagulation (warfarin, dabigatran, factor‑Xa inhibitors), criteria for surgical evacuation, intracranial pressure control, seizure prophylaxis, and monitoring?

Immediate Management of Acute Intracerebral Hemorrhage

For adults with acute intracerebral hemorrhage, immediately obtain non-contrast CT imaging, lower systolic blood pressure to <140 mmHg within 1 hour if presenting within 6 hours of onset, reverse anticoagulation urgently with prothrombin complex concentrate for warfarin (plus vitamin K), idarucizumab for dabigatran, or andexanet alfa for factor-Xa inhibitors, evacuate cerebellar hemorrhages >15 mL or those causing brainstem compression/hydrocephalus, avoid routine seizure prophylaxis, and transfer to a facility with neurocritical care capabilities. 1

Rapid Neuroimaging

• Obtain non-contrast CT immediately as the gold standard for detecting acute hemorrhage; it is highly sensitive and widely available 1
• Perform CT within minutes of arrival, as 28-38% of patients scanned within 3 hours show hematoma expansion on follow-up imaging 1
• Consider CT angiography (CTA) to identify contrast extravasation ("spot sign"), which predicts high risk of hematoma expansion and helps guide intensity of treatment 1
• MRI with gradient echo or T2*-susceptibility sequences is equally sensitive for acute blood but less practical in the emergency setting due to time constraints and patient tolerance 1

Blood Pressure Control

Target systolic BP <140 mmHg achieved within 1 hour for patients presenting within 6 hours of symptom onset with initial systolic BP 150-220 mmHg 1

• This intensive BP lowering is safe and may reduce hematoma expansion while improving functional outcomes 1
• Use treatment regimens that achieve smooth, sustained BP control with minimal variability, as this approach reduces hematoma expansion better than erratic control 1
• Avoid rapid BP drops that could compromise cerebral perfusion pressure; maintain CPP >60 mmHg 1
• Titratable intravenous agents are preferred (nicardipine, labetalol, clevidipine) over bolus medications to achieve steady control 2

Critical Pitfall

Do not delay BP treatment while awaiting specific agent recommendations—no single agent has proven superiority, so use what is immediately available 1

Reversal of Anticoagulation

Warfarin (Vitamin K Antagonists)

Administer prothrombin complex concentrate (PCC) immediately plus intravenous vitamin K 1, 3

• PCC is strongly preferred over fresh frozen plasma due to faster reversal and smaller volume 3
• This represents the highest quality recommendation for warfarin reversal 1

Dabigatran (Direct Thrombin Inhibitor)

Administer idarucizumab 5 grams IV as the specific reversal agent 1, 3

• This is a strong recommendation based on the availability of a specific antidote 3

Factor-Xa Inhibitors (Rivaroxaban, Apixaban, Edoxaban)

Administer andexanet alfa as the preferred reversal agent 1, 3

• If andexanet alfa is unavailable, use high-dose PCC (50 IU/kg) as second-line therapy 3
• For edoxaban specifically, high-dose PCC is recommended when andexanet alfa is not available 3

Antiplatelet Agents

Do not administer platelet transfusions in patients on antiplatelet therapy unless emergency surgery is planned or severe thrombocytopenia exists 1

• Platelet transfusions outside these settings appear to worsen outcomes 1
• There is insufficient RCT evidence to guide routine reversal strategies for antiplatelet-associated ICH 1

Criteria for Surgical Evacuation

Cerebellar Hemorrhage (Strong Indication)

Immediately evacuate cerebellar hemorrhages >15 mL OR any cerebellar hemorrhage causing neurological deterioration, brainstem compression, or hydrocephalus 1, 2, 4

• This is a Class I recommendation with the strongest evidence base 2, 4
• External ventricular drain (EVD) alone is insufficient and potentially harmful when brainstem compression exists 2

Supratentorial Hemorrhage (Selective Indication)

Consider early surgery for lobar hemorrhages within 1 cm of cortical surface in patients with GCS 9-12 1, 4

• This represents approximately 29% relative improvement in functional outcomes compared to medical management 4
• Do not perform routine surgical evacuation for supratentorial ICH, as overall evidence does not support benefit 1
• Deep hemorrhages (thalamic, basal ganglia) have worse outcomes with surgery compared to medical management 4, 5

Absolute Contraindications to Surgery

• GCS ≤8 (comatose patients) consistently show worse outcomes with surgical intervention 1, 4, 5
• Stable or improving neurological status on medical management 5

Critical Pitfall

Do not equate mortality reduction with functional improvement—some interventions reduce death but do not improve disability outcomes 4, 5

Intracranial Pressure Control

Elevate head of bed 20-30 degrees to facilitate venous drainage 2, 4

• Avoid hypo-osmolar fluids that worsen cerebral edema 2, 4
• Treat hypoxia, hypercarbia, and hyperthermia aggressively as these exacerbate elevated ICP 2, 4
• Consider external ventricular drain (EVD) for patients with intraventricular hemorrhage causing hydrocephalus 1
• Mannitol or hypertonic saline can be used emergently for worsening edema or impending herniation, but there is no indication for routine prophylactic use in small hematomas 6

ICP Monitoring

• Invasive ICP monitoring may be considered in patients with GCS ≤8, significant intraventricular hemorrhage, or clinical evidence of transtentorial herniation 1
• However, RCT evidence for routine ICP monitoring improving outcomes is lacking 1

Seizure Management

Do not use prophylactic antiseizure medications in the absence of clinical or electrographic seizures 1

• Prophylactic antiseizure drugs do not improve long-term seizure control or functional outcomes 1
• This represents a change from historical practice and is based on moderate-quality evidence 1
• Treat only clinically evident or electrographically confirmed seizures with appropriate antiepileptic drugs 1

Critical Pitfall

Avoid the outdated practice of routine seizure prophylaxis, which adds medication burden without benefit 1

Monitoring and Supportive Care

Admit all ICH patients to a dedicated stroke unit or neurocritical care unit 1

• Stroke unit care reduces both death and dependency compared to general ward care (high-quality evidence, strong recommendation) 1
• Perform frequent neurological assessments using standardized scales (NIHSS, GCS) 1
• 15% of patients deteriorate within the first hour of hospital presentation, requiring intensive monitoring 1

Venous Thromboembolism Prophylaxis

Use intermittent pneumatic compression devices immediately upon admission 1

• Do not use graduated compression stockings alone, as they are ineffective 1
• Initiate subcutaneous heparin within 48 hours in stable patients without ongoing bleeding 6

Additional Supportive Measures

• Maintain normothermia; treat fever aggressively 1
• Provide adequate oxygenation; intubate if GCS is compromised or airway protection is needed 2
• Avoid prophylactic corticosteroids, which provide no benefit 1

Transfer Considerations

Rapidly transfer patients to facilities with neurocritical care and neurosurgical capabilities when these are not available at the initial hospital 1

• Regional systems of care that facilitate rapid transfer improve outcomes 1
• Do not delay transfer for patients who may benefit from specialized interventions (cerebellar hemorrhage, young patients with lobar hemorrhage) 1