What is the appropriate management of an acute intracranial hemorrhage, from emergency stabilization and imaging to anticoagulant reversal, blood pressure control, osmotherapy, seizure prophylaxis, surgical intervention, ICU monitoring, and secondary prevention?

Management of Intracranial Hemorrhage

Patients with acute intracranial hemorrhage should be managed in a neuroscience intensive care unit with immediate blood pressure control to systolic 140-160 mmHg within 6 hours, anticoagulation reversal if applicable, serial neuroimaging at 6,24, and 48 hours, and avoidance of routine hemostatic therapy in non-anticoagulated patients. 1

Emergency Stabilization and Initial Care Setting

Admit all ICH patients to a neuroscience intensive care unit or stroke unit, as this setting reduces in-hospital mortality compared to general wards and provides the infrastructure for frequent monitoring and rapid intervention. 1, 2

• Stabilize airway, breathing, and circulation first—intubate patients with Glasgow Coma Scale ≤8 or those unable to protect their airway. 1, 3
• Establish continuous arterial line monitoring for patients requiring IV antihypertensives, as automated cuff monitoring is inadequate for precise titration. 2
• Perform hourly neurologic examinations using Glasgow Coma Scale and NIH Stroke Scale, as 27% of surgical interventions are prompted by delayed clinical or imaging findings. 4

Immediate Imaging Protocol

Obtain non-contrast head CT immediately to confirm diagnosis and establish baseline hematoma size. 3, 5

Repeat CT at 6,24, and 48 hours to detect hematoma expansion, which occurs in 28-38% of patients scanned within 3 hours and is associated with poor outcomes. 6, 4

Perform CT angiography (CTA) to identify underlying vascular lesions in patients with: 6

• Lobar hemorrhage location
• Age <55 years
• No history of hypertension
• Presence of subarachnoid hemorrhage
• Unusual hematoma shape or location

Blood Pressure Management

Target systolic blood pressure of 140-160 mmHg within 6 hours of symptom onset, as this range balances prevention of hematoma expansion against maintaining cerebral perfusion. 1, 6, 7

Critical safety parameters:

• Never reduce systolic BP by more than 70 mmHg within the first hour—excessive drops cause acute kidney injury, early neurological deterioration, and compromised cerebral perfusion. 6, 7, 2
• Maintain mean arterial pressure <130 mmHg. 7
• Maintain cerebral perfusion pressure ≥60 mmHg at all times, especially if elevated intracranial pressure develops. 1, 6, 7
• Avoid lowering systolic BP below 130 mmHg acutely, as this is potentially harmful. 2

Medication selection:

• Labetalol 5-20 mg IV bolus every 15 minutes or 2 mg/min continuous infusion is first-line, as it leaves cerebral blood flow relatively intact and does not increase intracranial pressure. 2
• Nicardipine starting at 5 mg/hour IV infusion is an alternative first-line agent, particularly favored in North America. 2
• Avoid nitroprusside and other venous vasodilators—they may worsen intracranial pressure and affect hemostasis negatively. 2

Monitoring requirements:

• Check BP every 15 minutes until stabilized, then every 30-60 minutes for the first 24-48 hours. 6, 7
• Transition to oral agents after 24-48 hours once acute control is achieved and patient is stable. 2

Long-term target: After hospital discharge, maintain BP <130/80 mmHg for secondary prevention, as hypertension is the most important modifiable risk factor for recurrent ICH. 6, 7

Anticoagulation Reversal

Immediately reverse ongoing anticoagulant treatment with dedicated reversal agents in patients with ICH. 1

Withhold all anticoagulants and antiplatelet agents for at least 24 hours after the hemorrhage. 6

Do NOT routinely transfuse platelets in patients taking aspirin or clopidogrel—there is no evidence this improves outcomes. 1, 8

Avoid hemostatic therapy (including recombinant factor VIIa) for acute ICH not associated with antithrombotic drug use, as it does not improve outcomes and increases thromboembolic complications. 1, 8

Resuming anticoagulation: The decision requires balancing recurrent hemorrhage risk (2.1-3.7% per patient-year) against thromboembolic risk. 6

• For mechanical heart valves: withhold oral anticoagulation for at least 5 days if infarct is >35% of cerebral hemisphere or if hypertension is uncontrolled. 6
• Do not resume before 24 hours and without repeat imaging to confirm hemorrhage stability. 6

Osmotherapy and Intracranial Pressure Management

Use a graded approach starting with simple measures:

• Elevate head of bed to 30 degrees. 1
• Provide adequate analgesia and sedation. 1

For elevated ICP requiring aggressive therapy:

• Osmotic diuretics (mannitol or hypertonic saline). 1
• Drainage of CSF via ventricular catheter (ventriculostomy). 1, 4
• Neuromuscular blockade. 1
• Hyperventilation (temporary measure). 1

These interventions require concomitant ICP and blood pressure monitoring with goal to maintain cerebral perfusion pressure >70 mmHg. 1

Avoid corticosteroids—there is moderate-quality evidence they should not be used. 1

Seizure Management

Treat clinical seizures immediately with appropriate antiepileptic therapy. 1

Do NOT use prophylactic antiepileptic drugs routinely—they confer no benefit in preventing seizures or improving outcomes. 8

Consider prophylaxis only in patients with lobar hemorrhage who are at higher risk of early seizures, using medications that can be administered IV during hospitalization and orally after discharge. 1

Surgical Intervention

Early surgery may be considered for patients with Glasgow Coma Scale score 9-12, though this is a weak recommendation based on moderate-quality evidence. 1

Conventional craniotomy for hematoma evacuation does not improve outcomes in most patients. 9

Ventriculostomy is indicated for patients with hydrocephalus or intraventricular hemorrhage requiring CSF drainage. 1, 4

Minimally invasive surgical techniques may be valuable but require further evaluation. 9

Venous Thromboembolism Prophylaxis

Use intermittent pneumatic compression (IPC) in immobile patients—this has strong evidence support. 1

Avoid graduated compression stockings alone—they are less effective than IPC and not more effective than control. 1

Pharmacological prophylaxis with UFH or LMWH:

• Begin after documenting hemorrhage stability on CT, typically 24-48 hours after ICH onset. 1, 6
• The earliest safe start time in studies was 25 hours after admission. 1
• Hematoma size, not timing of prophylaxis, is independently associated with hemorrhagic expansion. 1

Temperature and Glucose Management

Treat fever aggressively to normal levels, as fever duration is independently associated with poor outcome and increases intracranial volume homeostasis causing intracranial hypertension. 1

Treat hyperglycemia >140 mg/dL, as persistent hyperglycemia during the first 24 hours is associated with poor outcomes. 1

• Consider insulin administration for glucose >185 mg/dL and possibly >140 mg/dL. 1

Common Pitfalls to Avoid

• Delaying blood pressure treatment beyond 6 hours increases hematoma expansion risk. 6, 7
• Allowing BP to remain >160 mmHg directly increases risk of hematoma expansion and neurological deterioration. 6, 7
• Rapid uncontrolled BP drops >70 mmHg cause renal injury and compromised cerebral perfusion. 6, 7, 2
• Resuming anticoagulation before 24 hours without repeat imaging risks hemorrhagic expansion. 6
• Failing to investigate for structural lesions in younger patients or those with lobar hemorrhages may miss treatable vascular malformations. 6
• Using prophylactic antiepileptics routinely provides no benefit. 8
• Administering hemostatic therapy to non-anticoagulated patients does not improve outcomes and increases thromboembolic complications. 1, 8