How should an acute intracranial hemorrhage be managed, including airway and circulation support, blood pressure control, reversal of anticoagulation (warfarin, dabigatran, factor Xa inhibitors), cessation of antiplatelet agents, seizure prophylaxis, intracranial pressure management, and criteria for neurosurgical intervention?

Management of Acute Intracranial Hemorrhage

Admit all patients with intracranial hemorrhage immediately to an intensive care unit or dedicated stroke unit with neuroscience expertise, as this reduces mortality and improves functional outcomes. 1

Immediate Airway and Circulation Support

• Secure the airway with endotracheal intubation if Glasgow Coma Scale ≤8, as these patients cannot protect their airway and are at high risk for aspiration. 2
• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during initial resuscitation, particularly if there is concurrent systemic hemorrhage requiring control. 2
• Maintain PaO₂ between 60-100 mmHg and PaCO₂ between 35-40 mmHg; avoid hyperventilation except as a temporary bridge measure for impending herniation. 2
• Perform formal dysphagia screening before any oral intake to reduce pneumonia risk. 1

Blood Pressure Control

For patients presenting with systolic blood pressure 150-220 mmHg, immediately lower systolic blood pressure to 130-140 mmHg within 1 hour of presentation and maintain this target for at least 7 days. 3 This approach is safe, does not reduce perihematoma cerebral blood flow, and improves functional outcomes. 3, 1

• Begin blood pressure lowering within 6 hours of symptom onset, ideally within 2 hours, to minimize hematoma expansion. 3
• Use any rapid-onset, short-acting intravenous antihypertensive (such as nicardipine) to facilitate easy titration. 3
• Do not reduce systolic blood pressure below 130 mmHg, as this is associated with worse outcomes. 3
• If intracranial pressure is elevated, maintain cerebral perfusion pressure ≥60 mmHg at all times. 3

Reversal of Anticoagulation

Warfarin (Vitamin K Antagonists)

Immediately stop warfarin, administer intravenous vitamin K, and give prothrombin complex concentrates (PCC) to rapidly correct INR. 4, 1 PCC is strongly preferred over fresh frozen plasma because it achieves faster hemostasis. 4, 1

• The goal is rapid normalization of INR to prevent hematoma expansion. 1
• While one large study showed PCC reduced hematoma size compared to plasma, it did not reduce mortality, highlighting that reversal alone may not be sufficient. 4

Dabigatran (Direct Thrombin Inhibitor)

Administer idarucizumab 5 g intravenously for dabigatran-associated intracranial hemorrhage. 4 This specific reversal agent normalizes coagulation tests within 10-30 minutes in 95% of patients. 4

• Measure dabigatran concentration before and 12-18 hours after idarucizumab administration, as some patients may experience rebound dabigatran levels requiring a second 5 g dose. 4
• Consider hemodialysis in addition to idarucizumab for patients with very high dabigatran concentrations, though the majority of such patients also received PCC. 4

Factor Xa Inhibitors (Rivaroxaban, Apixaban, Edoxaban)

Administer andexanet alfa for factor Xa inhibitor-associated intracranial hemorrhage. 4 Andexanet alfa significantly reduces anti-factor Xa levels. 4

• In the absence of andexanet alfa, four-factor PCC is a reasonable alternative, though evidence is less robust. 4

Unfractionated Heparin

Administer intravenous protamine to reverse unfractionated heparin, but do not exceed 50 mg per 10 minutes due to risk of hypotension and bronchoconstriction. 4 Repeated smaller doses are preferable given heparin's short half-life and protamine's weak anticoagulant properties. 4

Low Molecular Weight Heparin

Administer intravenous protamine to partially reverse low molecular weight heparin, recognizing that protamine only partially affects anti-factor Xa levels. 4 Andexanet alfa also significantly reduces anti-factor Xa levels in enoxaparin-treated patients. 4

Severe Thrombocytopenia

Transfuse platelets to achieve a count >50 × 10⁹/L (ideally >50,000/mm³) in patients with severe thrombocytopenia. 1, 2 Higher platelet counts are advisable before emergency neurosurgery or ICP monitor insertion. 2

Cessation of Antiplatelet Agents

Stop all antiplatelet agents immediately upon diagnosis of intracranial hemorrhage. 4

• Do not administer platelet transfusions to patients on aspirin who are not scheduled for emergency neurosurgery, as this is potentially harmful and increases mortality. 4 The PATCH trial demonstrated that platelet transfusion in antiplatelet-associated ICH without planned surgery worsens outcomes. 4
• For patients on aspirin requiring emergency neurosurgery, platelet transfusion might be considered to reduce postoperative bleeding, though evidence is limited. 4
• The effectiveness of desmopressin with or without platelet transfusions to reduce hematoma expansion is uncertain. 4

Seizure Management

Treat clinical seizures with antiseizure medications when they occur. 1 Patients with electrographic seizures on EEG and altered mental status should also receive antiseizure drugs. 1

• Do not use prophylactic antiseizure drugs routinely, as they are associated with increased death and disability. 1 Reserve antiseizure medications for patients with documented seizures only.

Intracranial Pressure Management

Monitor intracranial pressure in patients with Glasgow Coma Scale ≤8, clinical evidence of transtentorial herniation, significant intraventricular hemorrhage, or hydrocephalus. 1

• Maintain cerebral perfusion pressure between 50-70 mmHg depending on autoregulation status. 1
• Place a ventricular catheter for CSF drainage in patients with decreased level of consciousness due to hydrocephalus. 1
• Ensure PT/aPTT <1.5 times normal control and platelet count >50,000/mm³ before inserting ICP monitors. 2
• Consider temporary hypocapnia (PaCO₂ below 35 mmHg) only as a bridge for cerebral herniation while awaiting emergency neurosurgery. 2

Neurosurgical Intervention Criteria

Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus must undergo surgical removal of the hemorrhage as soon as possible. 1, 2 Do not delay with ventricular catheter placement alone. 1

• Consider early surgery for supratentorial intracerebral hemorrhage in patients with Glasgow Coma Scale 9-12. 1
• Superficial lobar hemorrhages within 1 cm of the cortical surface may benefit from evacuation. 1
• Patients showing signs of impending herniation or significant mass effect with midline shift require urgent neurosurgical consultation. 2

Prevention of Secondary Complications

Apply intermittent pneumatic compression devices on the day of hospital admission for venous thromboembolism prophylaxis. 1, 2 This mechanical prophylaxis lowers deep vein thrombosis incidence without increasing bleeding risk. 1

• Do not use graduated compression stockings, as they provide no benefit and may cause harm. 1
• Monitor and manage glucose levels, avoiding both hyperglycemia and hypoglycemia. 1
• Maintain continuous cardiopulmonary monitoring including automated blood pressure, ECG telemetry, and pulse oximetry. 1
• Transfuse red blood cells for hemoglobin <7 g/dL, with higher thresholds for elderly patients or those with limited cardiovascular reserve. 2

Interventions to Avoid

Never administer corticosteroids for intracerebral hemorrhage, as they provide no benefit and may cause harm. 1

Do not administer hemostatic therapy such as recombinant factor VIIa for acute ICH not associated with antithrombotic drug use, as it reduces hematoma expansion but does not improve outcomes and increases thromboembolic complications. 1

Common Pitfalls

• Do not delay neurosurgical consultation while attempting medical management alone in patients with life-threatening mass lesions, particularly cerebellar hemorrhages with hydrocephalus. 2
• Failing to correct coagulopathy rapidly in anticoagulated patients leads to continued hematoma expansion and worse outcomes. 1
• Delaying neuroimaging misses opportunities for intervention, as hematoma expansion commonly occurs within the first 3 hours after onset (38% of patients scanned within 3 hours). 4
• Do not allow hypotension or hypoxia, which worsen secondary brain injury. 2
• Overlooking secondary causes of ICH (vascular malformations, tumors, cerebral venous thrombosis) in patients with atypical presentations or unusual hemorrhage locations can lead to missed diagnoses. 1

Long-Term Management

Transition to a target blood pressure <130/80 mmHg for secondary prevention of intracerebral hemorrhage recurrence, as hypertension is the most important modifiable risk factor. 3 Blood pressure lowering significantly reduces the risk of first and recurrent intracerebral hemorrhage. 3

• Strongly discourage smoking, heavy alcohol use, and cocaine use. 1
• All ICH patients should have access to multidisciplinary rehabilitation services beginning as early as possible. 1