What is the recommended acute diagnostic and therapeutic management for a patient with suspected intracerebral hemorrhage, including imaging, blood pressure control, anticoagulation reversal, and surgical considerations?

Acute Management of Intracerebral Hemorrhage

For patients with suspected intracerebral hemorrhage, immediately obtain non-contrast CT imaging to confirm diagnosis, aggressively lower systolic blood pressure to <160 mmHg (target 130-140 mmHg if >150 mmHg on presentation), reverse any coagulopathy with appropriate agents, and consult neurosurgery urgently for cerebellar hemorrhages or those requiring surgical intervention. 1, 2

Immediate Diagnostic Approach

Neuroimaging

• Obtain non-contrast CT of the head immediately – this is the gold standard for diagnosing acute ICH and must be performed before any treatment decisions 1
• CT is preferred over MRI due to speed, availability, and equivalent sensitivity for acute hemorrhage 1
• Complete initial imaging within 45 minutes of emergency department arrival 1
• Obtain repeat CT within 24 hours to assess for hematoma expansion, particularly in patients with declining neurological status or GCS ≤8 1, 2

Advanced Imaging Considerations

• Consider CT angiography (CTA) within the first few hours if the patient is at risk for hematoma expansion or if secondary causes are suspected 1
• CTA "spot sign" (contrast extravasation) predicts hematoma expansion and worse outcomes 1
• Obtain CTA/MRA for patients with: age <55 years, lobar location, no hypertension history, or unusual hematoma characteristics suggesting vascular malformation or tumor 1

Blood Pressure Management

Acute Blood Pressure Control

• For systolic BP >150 mmHg presenting within 6 hours: aggressively reduce to target 130-140 mmHg 1, 2
• Avoid BP reductions ≥60 mmHg within the first hour – this may worsen outcomes 3
• Maintain systolic BP <160 mmHg continuously for optimal outcomes 1, 2
• For unsecured aneurysms: keep systolic BP <160 mmHg while avoiding hypotension <110 mmHg 2
• Maintain mean arterial pressure >80 mmHg and cerebral perfusion pressure ≥60 mmHg 1, 4

The 2022 AHA/ASA guidelines represent the most current evidence, superseding the 2007 recommendation of maintaining systolic BP <180 mmHg 1. The shift toward more aggressive control (130-140 mmHg) is based on evidence that this reduces hematoma expansion without compromising cerebral perfusion 2, 3.

Reversal of Coagulopathy

Vitamin K Antagonists (Warfarin)

• Administer four-factor prothrombin complex concentrate (PCC) immediately 1, 2
• Give intravenous vitamin K 5-10 mg slowly 1
• Do NOT use fresh frozen plasma as first-line – PCC is superior 1

Direct Oral Anticoagulants

• For dabigatran: administer idarucizumab (if unavailable, consider hemodialysis) 2, 5, 3
• For factor Xa inhibitors (rivaroxaban, apixaban): administer four-factor PCC 50 U/kg or activated PCC 50 U/kg 2, 5
• Andexanet alfa may be used for anti-Xa agents where available 3

Heparin

• Administer protamine sulfate 1 mg per 100 units of heparin given in previous 2-3 hours (maximum 50 mg single dose) 2, 5

Antiplatelet Agents

• Do NOT routinely transfuse platelets in patients taking aspirin or clopidogrel – no evidence of benefit and may cause harm 6

Airway and Respiratory Management

• Intubate patients with GCS ≤8 for airway protection 4, 7
• Maintain PaO₂ 60-100 mmHg 4
• Maintain PaCO₂ 35-40 mmHg to prevent cerebral vasoconstriction and ischemia 4
• Elevate head of bed to 30 degrees to reduce intracranial pressure 2, 5

Intracranial Pressure Management

Monitoring Indications

• Consider ICP monitoring for patients with GCS ≤8, hydrocephalus, or clinical evidence of herniation 2

Treatment Measures

• Use 0.9% normal saline – avoid hypotonic fluids 2, 5
• Osmotic agents (mannitol) for elevated ICP 2
• CSF drainage via external ventricular drain if hydrocephalus present 1
• Hyperventilation only as temporary measure (has adverse effects) 2

Surgical Considerations

Clear Indications for Surgery

• Cerebellar hemorrhage with neurological deterioration, brainstem compression, or hydrocephalus from ventricular obstruction requires urgent surgical evacuation 1, 2, 4
• This is the strongest surgical indication with clearest benefit 1, 2

Supratentorial ICH

• Consider surgery for superficial lobar hematomas within 1 cm of cortical surface, performed within 96 hours 2
• Overall benefit of supratentorial surgery remains uncertain – no phase III trial has shown clear benefit 3
• Meta-analyses suggest possible benefit in selected patients 3

Hydrocephalus

• External ventricular drainage for obstructive hydrocephalus 1, 2

Prevention of Secondary Complications

Venous Thromboembolism Prophylaxis

• Initiate intermittent pneumatic compression immediately 2, 4
• Add pharmacological prophylaxis within 24 hours after bleeding stabilizes 4

Medical Complications

• Monitor for pneumonia, cardiac events, and acute kidney injury 2, 5
• Maintain normothermia 4
• Do NOT use prophylactic antiepileptic drugs – no benefit shown 6

Critical Care and Monitoring

• Admit to intensive care unit or stroke unit for continuous monitoring 2, 4, 3
• Assess neurological status frequently using NIHSS and GCS 1
• Over 20% of patients deteriorate between prehospital assessment and ED arrival 1
• 28-38% of patients scanned within 3 hours show hematoma expansion on follow-up 1

Prognostication and Goals of Care

• Avoid early pessimistic prognostication in the first 24-48 hours – this can become a self-fulfilling prophecy 4, 3
• ICH volume and admission GCS are the strongest predictors of 30-day mortality 2
• Most patients present with small ICHs that are survivable with aggressive care 1, 2
• Early do-not-resuscitate orders should be used judiciously 3

Common Pitfalls to Avoid

• Do not delay imaging – neuroimaging is mandatory and cannot be replaced by clinical assessment 1, 4
• Do not use clinical features alone to distinguish hemorrhagic from ischemic stroke 1
• Do not delay intubation in patients with declining mental status 4
• Do not allow hypotension or hypoxia – these worsen secondary brain injury 4
• Do not transfuse platelets routinely for antiplatelet-associated ICH 6
• Do not use recombinant factor VIIa routinely – reduces hematoma expansion but does not improve outcomes and increases thromboembolic complications 6