Emergency Management of Acute Intracerebral Hemorrhage
Immediate Actions in the Emergency Department
All patients with suspected ICH require immediate non-contrast CT imaging to confirm diagnosis and distinguish from ischemic stroke. 1, 2 CT is the gold standard for identifying acute hemorrhage and must not be delayed. 2, 3
Admit all ICH patients to an intensive care unit or dedicated stroke unit with neuroscience expertise—this reduces mortality. 1, 2 Every emergency department should be prepared to treat ICH patients or have a rapid transfer plan to a tertiary care center. 2
Initial Assessment
- Record baseline neurological severity using Glasgow Coma Scale (GCS) or NIH Stroke Scale (NIHSS) immediately. 2 These scores guide triage and prognostication. 2
- Recognize that >20% of patients deteriorate between prehospital assessment and ED arrival, with an additional 15-23% worsening within the first few hours. 2 Early recognition of this trend is critical for escalation of care. 2
- Obtain CT angiography and contrast-enhanced CT to identify patients at risk for hematoma expansion. 2 Approximately 38% of patients scanned within the first 3 hours demonstrate expansion. 2
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, 2 Begin BP control within 6 hours of ICH onset. 2
- Avoid BP reductions ≥60 mmHg within 1 hour, as careful, targeted, and sustained treatment optimizes outcomes. 4
- Maintain systolic BP >100 mmHg or mean arterial pressure >80 mmHg during emergency neurosurgery or interventions for life-threatening hemorrhage. 1
Reversal of Anticoagulation and Coagulopathy
Vitamin K Antagonists (Warfarin)
Immediately discontinue warfarin, give intravenous vitamin K, and administer prothrombin complex concentrates (PCC) to rapidly normalize INR. 2 PCC is strongly preferred over fresh frozen plasma because it achieves faster hemostasis. 2, 4
- Maintain PT/aPTT <1.5 times normal control during emergency interventions. 1
Direct Oral Anticoagulants
For dabigatran-related ICH, give idarucizumab 5 g intravenously—coagulation tests normalize within 10-30 minutes in ≈95% of patients. 2
- Measure dabigatran concentration before and 12-18 hours after idarucizumab; a rebound in drug level may require a second 5 g dose. 2
- In patients with very high dabigatran concentrations, consider adding hemodialysis. 2
For factor Xa inhibitors (rivaroxaban, apixaban, edoxaban), administer andexanet alfa—the agent markedly lowers anti-factor Xa activity. 2
- If andexanet alfa is unavailable, four-factor PCC is a reasonable alternative. 2
Heparin-Based Anticoagulation
For unfractionated heparin, give intravenous protamine but do not exceed 50 mg per 10 minutes to avoid hypotension and bronchoconstriction. 2
For low-molecular-weight heparin, give intravenous protamine (partial reversal) or andexanet alfa. 2
Antiplatelet Therapy
Stop all antiplatelet agents immediately after diagnosis of ICH. 2
Do not give platelet transfusions to patients on aspirin who are not scheduled for emergency neurosurgery—this practice is associated with increased mortality. 2 The PATCH trial demonstrated worsened outcomes with platelet transfusion in non-surgical aspirin-related ICH. 2
- If emergency neurosurgery is required for an aspirin-treated patient, platelet transfusion may be considered, although supporting data are limited. 2
Thrombocytopenia
For severe thrombocytopenia, transfuse platelets to achieve count >50,000/mm³ for life-threatening hemorrhage or >50,000/mm³ for emergency neurosurgery. 1, 2
Airway and Respiratory Management
Maintain arterial partial pressure of oxygen (PaO₂) between 60-100 mmHg during emergency interventions. 1
Maintain arterial partial pressure of carbon dioxide (PaCO₂) between 35-40 mmHg during emergency interventions. 1
- In cases of cerebral herniation awaiting or during emergency neurosurgery, use osmotherapy and/or temporary hypocapnia. 1
Intracranial Pressure Management
Monitor ICP in patients with GCS ≤8, clinical evidence of transtentorial herniation, significant intraventricular hemorrhage, or hydrocephalus. 2
Maintain cerebral perfusion pressure (CPP) ≥60 mmHg when ICP monitoring becomes available, adjusting based on neuromonitoring data and cerebral autoregulation status. 1, 2
Place a ventricular catheter for CSF drainage in patients with decreased level of consciousness due to hydrocephalus. 2
- Use a stepwise approach for elevated ICP, reserving more aggressive interventions for situations when no response is observed. 1
Surgical Indications
Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus must undergo surgical removal as soon as possible—do not delay with ventricular catheter alone. 1, 2, 3
Consider early surgery for supratentorial ICH with GCS 9-12. 2
Superficial lobar hemorrhages (within 1 cm of cortical surface) may benefit from evacuation. 2
Prevention of Secondary Complications
Venous Thromboembolism Prophylaxis
Use intermittent pneumatic compression beginning on the day of hospital admission. 1, 2 This lowers the incidence of deep-vein thrombosis without increasing bleeding risk. 2
Do not use graduated compression stockings—they provide no benefit and may cause harm. 2
Seizure Management
Treat clinical seizures with antiseizure medications. 2
Patients with electrographic seizures on EEG and altered mental status should receive antiseizure drugs. 2
Do not use prophylactic antiseizure drugs routinely—they are associated with increased death and disability. 2
Glucose and Temperature Management
Monitor and manage glucose levels, avoiding both hyperglycemia and hypoglycemia. 2
Treat fever aggressively. 3
Dysphagia Screening
Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk. 2
Transfusion Thresholds
Transfuse red blood cells for hemoglobin <7 g/dL during emergency interventions. 1 Higher thresholds may be used in elderly patients or those with limited cardiovascular reserve. 1
During massive transfusion protocol, transfuse RBCs/plasma/platelets at a ratio of 1:1:1, then modify according to laboratory values. 1
Use point-of-care tests (TEG or ROTEM) to assess and optimize coagulation function during emergency interventions. 1
Interventions to AVOID
Never administer corticosteroids for ICH—they provide no benefit and may cause harm. 2
Do not use hemostatic therapy (such as recombinant factor VIIa) for acute ICH not associated with antithrombotic drug use—it reduces hematoma expansion but does not improve outcomes and increases thromboembolic complications. 2, 4
Rehabilitation and Secondary Prevention
All ICH patients should have access to multidisciplinary rehabilitation services beginning as early as possible. 2
Control blood pressure long-term in all ICH survivors—this is the single most important modifiable risk factor for recurrence. 2 Treated hypertension reduces ICH risk (OR 1.4) compared to untreated hypertension (OR 3.5). 2
Strongly discourage smoking, heavy alcohol use, and cocaine use. 2
Common Pitfalls
- Delaying neuroimaging can miss early hematoma expansion, which occurs in 38% of patients within the first 3 hours. 2
- Failing to correct coagulopathy rapidly in patients on anticoagulants leads to continued hematoma expansion and worse outcomes. 2
- Overlooking secondary causes of ICH (vascular malformations, tumors, cerebral vein thrombosis) in patients with atypical presentations or hemorrhage locations. 2
- Early do-not-resuscitate orders or withdrawal of active care should be used judiciously in the first 24-48 hours—early prognostication is difficult. 4