What is the management of intracerebral hemorrhage?

Management of Intracerebral Hemorrhage (ICH)

Intracerebral hemorrhage is a medical emergency requiring immediate admission to an intensive care unit or dedicated stroke unit with neuroscience expertise, as this approach reduces mortality and improves outcomes. 1

Immediate Emergency Actions

Prehospital and ED Management

• Provide airway management if needed and cardiovascular support, then transport to the closest facility equipped for acute stroke care 2
• Obtain rapid CT imaging immediately upon ED arrival to confirm diagnosis and distinguish ICH from ischemic stroke—CT is the gold standard for identifying acute hemorrhage 1
• Perform baseline severity scoring using Glasgow Coma Scale (GCS) or NIH Stroke Scale as part of initial evaluation 2, 1
• Consider CT angiography to identify patients at risk for hematoma expansion 1

Critical pitfall: Over 20% of patients experience a GCS decrease of ≥2 points between prehospital assessment and ED evaluation, and another 15-23% deteriorate within hours of hospital arrival 2. Early deterioration is common because active bleeding may continue for hours after symptom onset 3.

Blood Pressure Management

For patients with systolic BP 150-220 mmHg without contraindications, immediately lower systolic BP to <140 mmHg—this is safe and improves functional outcomes. 1

• Begin BP control within 6 hours of ICH onset 1
• Avoid BP reductions ≥60 mmHg within 1 hour, as careful, targeted, and sustained treatment optimizes outcomes 4
• Minimize BP variability during the first 24 hours 4

Reversal of Coagulopathy

Vitamin K Antagonists (Warfarin)

• Immediately withhold the VKA 2
• Administer prothrombin complex concentrate (PCC)—preferred over fresh frozen plasma for rapid INR correction 1
• Give intravenous vitamin K 2

Direct Oral Anticoagulants

• Reverse dabigatran with idarucizumab 4
• Reverse anti-Xa agents with PCC or andexanet alfa (where available) 4

Thrombocytopenia

• Administer platelets for severe thrombocytopenia 2
• Maintain platelet count >50×10⁹/L in patients with ongoing bleeding 3

Critical principle: Anticoagulants increase hematoma expansion risk, and rapid reversal reduces this risk and may improve outcome 4.

Prevention of Secondary Complications

Venous Thromboembolism Prophylaxis

• Begin intermittent pneumatic compression on day of hospital admission 2, 1
• Do NOT use graduated compression stockings—they provide no benefit and may cause harm 1
• Consider pharmacological thromboprophylaxis within 24 hours after bleeding has stabilized 3

Seizure Management

• Treat clinical seizures with antiseizure medications 1
• Treat electrographic seizures on EEG with altered mental status 1
• Do NOT use prophylactic antiseizure drugs routinely—they are associated with increased death and disability 1

Other Supportive Measures

• Perform formal dysphagia screening before oral intake to reduce pneumonia risk 1
• Monitor and manage glucose levels, avoiding both hyperglycemia and hypoglycemia 1
• Maintain normothermia and manage fever aggressively 5
• Continuous cardiopulmonary monitoring including automated BP cuff, ECG telemetry, and pulse oximetry 1

Intracranial Pressure Management

• Monitor ICP in patients with GCS ≤8, clinical evidence of transtentorial herniation, significant intraventricular hemorrhage, or hydrocephalus 1
• Maintain cerebral perfusion pressure 50-70 mmHg depending on autoregulation status 1
• Place ventricular catheter for CSF drainage in patients with decreased consciousness due to hydrocephalus 1
• Use osmotic therapy (mannitol or hypertonic saline) for patients with clinical deterioration from cerebral swelling 5

Surgical Management

Cerebellar Hemorrhage

Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus require surgical removal as soon as possible—do NOT delay with ventricular catheter alone. 1

Supratentorial ICH

• Consider early surgery for patients with GCS 9-12 1
• Consider evacuation for superficial lobar hemorrhages (within 1 cm of cortical surface) 1
• For most supratentorial ICH, the usefulness of surgery is uncertain—no large phase III trial has shown overall benefit, though meta-analyses suggest potential advantages 3, 4

Interventions to AVOID

• NEVER administer corticosteroids for ICH—they provide no benefit and may cause harm 1
• Do NOT use hemostatic therapy (recombinant factor VIIa) for acute ICH not associated with antithrombotic drugs—it reduces hematoma expansion but does not improve outcomes and increases thromboembolic complications 1

Prognostication and Goals of Care

• Observe for 24-72 hours after initial stabilization to improve prognostic accuracy 5
• Avoid early do-not-resuscitate orders or withdrawal of active care in the first 24-48 hours—early prognostication is difficult 4
• Use formal prognostic tools when discussing outcomes with families 6
• Hematoma volume and admission GCS are the most powerful predictors of 30-day mortality 3

Critical principle: Most patients present with small ICH that are readily survivable with good medical care, warranting early aggressive treatment 3.

Rehabilitation and Long-Term Management

• All ICH patients should have access to multidisciplinary rehabilitation beginning as early as possible 1
• Control blood pressure long-term in all ICH survivors—this is the single most important modifiable risk factor for recurrence 1
• Strongly discourage smoking, heavy alcohol use, and cocaine use 1