What is the recommended management protocol for a patient with spontaneous (non‑traumatic) intracranial hemorrhage (ICH)?

Management Protocol for Spontaneous Intracerebral Hemorrhage

Immediate Diagnosis and Initial Stabilization

Perform urgent non-contrast CT scan immediately upon presentation to confirm ICH diagnosis and distinguish from ischemic stroke. 1 MRI with gradient echo sequences is equally sensitive but CT remains the gold standard due to speed and availability. 1

• Secure airway and provide ventilatory support if Glasgow Coma Scale (GCS) ≤8, as over 20% of patients deteriorate by ≥2 GCS points between prehospital assessment and ED arrival. 2, 3
• Establish IV access and initiate continuous cardiac monitoring. 2
• Perform baseline severity assessment using validated scales (GCS, NIHSS) immediately upon arrival. 1
• Obtain stat labs: CBC with platelets, PT/INR, aPTT, basic metabolic panel, troponin, and blood glucose. 1

Blood Pressure Management (First 6 Hours)

For patients presenting within 6 hours with systolic BP 150-220 mmHg and no immediate surgical plans, aggressively lower systolic BP to <140 mmHg using IV agents allowing precise titration. 1, 4

• Use nicardipine or labetalol as first-line agents for BP control. 4
• Never use GTN patches—they increase hematoma growth and worsen outcomes. 4
• Monitor BP every 15 minutes during active titration, then every 30-60 minutes for first 24-48 hours. 4
• Avoid hypotension (systolic <110 mmHg) as it compromises cerebral perfusion. 2, 3
• For patients with unsecured aneurysms, maintain systolic BP <160 mmHg. 2

Reversal of Anticoagulation (Immediate Priority)

Discontinue all anticoagulation immediately and initiate rapid reversal as soon as ICH is diagnosed—do not wait for lab results if anticoagulant use is suspected based on history and timing. 1

Warfarin-Associated ICH (INR ≥2.0):

• Administer 4-factor prothrombin complex concentrate (PCC) immediately—this is superior to fresh frozen plasma for rapid INR correction and limiting hematoma expansion. 1
• Give IV vitamin K (5-10 mg) directly after PCC to prevent later INR increase. 1
• For INR 1.3-1.9, consider PCC for rapid correction. 1

Direct Factor Xa Inhibitor-Associated ICH:

• Administer andexanet alfa to reverse factor Xa inhibitors (apixaban, rivaroxaban, edoxaban). 1
• If andexanet alfa unavailable, give 4-factor PCC (50 U/kg) or activated PCC (50 U/kg). 2, 5

Dabigatran-Associated ICH:

• Administer idarucizumab (specific reversal agent for dabigatran). 1, 5
• If idarucizumab unavailable, consider hemodialysis or give activated PCC (50 U/kg). 2, 5

Heparin-Associated ICH:

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

Antiplatelet-Associated ICH:

• Discontinue antiplatelet agents immediately. 5
• Do not routinely transfuse platelets—this does not improve outcomes and may cause harm. 1
• Platelet transfusion may be reasonable only before craniotomy and hematoma evacuation. 1

Neuroimaging Protocol

• Obtain serial head CT within first 24 hours to evaluate for hematoma expansion, which occurs in approximately 30% of patients. 1
• Perform additional CT if GCS decreases or neurological deterioration occurs to assess for expansion, hydrocephalus, brain swelling, or herniation. 1
• Consider CT angiography (CTA) within first few hours to identify spot sign or other markers predicting hematoma expansion risk. 1

Triage and Care Setting

Transfer all patients to centers providing full high-acuity neurological care with neurosurgical capabilities. 1

• Admit patients with moderate-to-severe ICH, intraventricular hemorrhage (IVH), hydrocephalus, or infratentorial location to neuro-specific ICU—this reduces mortality compared to general ICU. 1, 4
• Patients without ICU indications should receive care in dedicated stroke unit rather than general ward to reduce mortality. 1
• Ensure multidisciplinary teams trained in neurological assessment are available. 1
• Before transport, stabilize airway, gas exchange, and hemodynamics to prevent decompensation. 1

Surgical Intervention

For cerebellar hemorrhage with neurological deterioration, brainstem compression, or hydrocephalus, perform immediate surgical evacuation—this is a Class I recommendation. 1, 4, 3

• For ICH with hydrocephalus causing decreased consciousness, place external ventricular drain (EVD) immediately to reduce mortality. 1
• For larger supratentorial ICH, consider transfer to neurosurgical center, though benefit of routine evacuation remains uncertain. 1
• Supratentorial hematomas within 1 cm of cortical surface may benefit from surgery within 96 hours. 2

Intracranial Pressure Management

• Elevate head of bed to 30 degrees with neck in neutral midline position. 2, 3
• Consider ICP monitoring in patients with GCS ≤8, hydrocephalus, or clinical signs of herniation. 1, 2, 4
• For patients with spontaneous ICH or IVH and reduced consciousness, ICP monitoring and treatment might be considered to reduce mortality. 1
• Use bolus hyperosmolar therapy (mannitol) for transiently reducing elevated ICP. 1
• Do not use early prophylactic hyperosmolar therapy—efficacy for improving outcomes is not established. 1
• Never administer corticosteroids for elevated ICP—they provide no benefit and may cause harm. 1, 4
• Avoid hypotonic fluids; use 0.9% saline as crystalloid solution. 2

Hemostatic Therapy

Do not routinely administer recombinant factor VIIa—it reduces hematoma expansion but does not improve functional outcomes and increases thromboembolic complications. 1, 4, 6

• Tranexamic acid (TXA) efficacy remains uncertain; larger trials with earlier treatment windows are ongoing. 1

Seizure Management

• Treat clinical seizures with antiseizure drugs when they occur. 1, 4
• Do not use prophylactic antiseizure drugs routinely—they are associated with worse outcomes and increased death/disability. 1, 4
• Consider continuous EEG monitoring in comatose patients, as 94% of seizures in this population require ≥48 hours of monitoring to detect. 1

Prevention of Secondary Complications

• Initiate intermittent pneumatic compression for DVT prophylaxis once bleeding stabilizes. 2, 4
• Do not use graduated compression stockings—they show no benefit and potential harm. 4
• Perform formal dysphagia screening before any oral intake. 4
• Treat fever aggressively to normal levels. 1, 4
• Monitor and correct glucose abnormalities, avoiding both hyperglycemia and hypoglycemia. 4
• Admission hyperglycemia is associated with unfavorable outcomes and increased mortality. 1

Monitoring Protocol (First 24-48 Hours)

• Perform hourly neurological assessments using GCS and NIHSS for first 24 hours. 4
• Monitor BP every 15 minutes during active titration, then every 30-60 minutes. 4
• Assess for signs of increased ICP, herniation, or hydrocephalus development. 1
• Monitor for cardiac complications—elevated troponin on admission is associated with increased in-hospital mortality. 1

Common Pitfalls to Avoid

• Never delay anticoagulation reversal waiting for INR results—treat based on history and timing of anticoagulant use. 1
• Never use GTN patches for BP control in ICH patients. 4
• Never give prophylactic antiseizure drugs routinely. 1, 4
• Never administer corticosteroids for cerebral edema or elevated ICP. 1, 4
• Never transfuse platelets routinely in antiplatelet-associated ICH outside of pre-operative setting. 1
• Do not overlook underlying structural lesions—obtain CTA, MRI, or catheter angiography in young patients (<55 years), lobar hemorrhages, or when clinical suspicion exists for vascular malformation or tumor. 1

Long-Term Secondary Prevention (Post-Discharge)

• Maintain systolic BP <130 mmHg (ideally 120-130 mmHg) with home monitoring. 2
• Use ACE inhibitors, ARBs, or calcium channel blockers as first-line antihypertensives. 2
• Avoid routine anticoagulation restart unless life-threatening thromboembolic indication exists (mechanical heart valve, refractory PE). 2
• Mandate smoking cessation—tobacco markedly increases ICH recurrence risk. 2
• Limit alcohol to ≤2 drinks/day for men, ≤1 drink/day for women. 2
• Obtain baseline MRI with GRE/SWI sequences at 3 months to detect underlying vascular malformations or cerebral amyloid angiopathy. 2