How should an acute intracerebral hemorrhage be managed emergently, including imaging, blood pressure control, anticoagulant reversal, intracranial pressure management, neurosurgical indications, ICU admission, seizure prophylaxis, and secondary prevention?

Emergency Management of Acute Intracerebral Hemorrhage

Acute intracerebral hemorrhage (ICH) requires immediate CT imaging, aggressive blood pressure control to 130-150 mmHg systolic within 6 hours, rapid anticoagulation reversal with prothrombin complex concentrate when applicable, and neurosurgical consultation for cerebellar hemorrhages >3 cm or those with brainstem compression. 1, 2, 3

Immediate Imaging and Diagnosis

• Non-contrast head CT is mandatory as the gold-standard first-line imaging modality to confirm hemorrhage, determine location and volume, and identify complications such as hydrocephalus or mass effect 1, 2, 3
• Obtain initial CT within 3 hours of symptom onset because 28-38% of patients demonstrate hematoma expansion on subsequent imaging, which predicts clinical deterioration and increased mortality 1, 2
• CT angiography should be performed to identify patients at high risk for hematoma expansion (contrast extravasation within the hematoma) and to detect secondary causes such as arteriovenous malformations, aneurysms, or tumors, particularly in younger patients or those without hypertension 1, 3
• MRI with gradient echo sequences is as sensitive as CT for acute hemorrhage detection and more sensitive for chronic hemorrhage, but time, availability, and patient stability often preclude its use emergently 1, 4

Blood Pressure Management (First 6 Hours)

For patients presenting ≤6 hours after onset with systolic BP >150 mmHg and no immediate surgical plan, lower systolic BP to 130-150 mmHg in a controlled fashion 2, 3, 5

Specific BP Targets and Agents

• Intravenous nicardipine is the preferred agent due to easy titration: start at 5 mg/h, increase by 2.5 mg/h every 5-15 minutes up to 15 mg/h 3
• Intravenous labetalol (10-20 mg bolus or continuous infusion) is an acceptable alternative when nicardipine is contraindicated 3
• Maintain cerebral perfusion pressure ≥60 mmHg throughout treatment 2, 3, 5
• Continuous arterial line monitoring is recommended for patients receiving IV antihypertensives to ensure precise BP control 3
• Avoid aggressive SBP reduction below 130 mmHg, as this increases mortality 3
• Avoid BP reductions ≥60 mmHg within 1 hour, as careful, targeted, and sustained treatment optimizes functional outcomes 6

Critical Pitfall

• For patients with systolic BP >220 mmHg, vomiting, severe headache, or decreased consciousness, ICH is more likely, but neuroimaging remains mandatory as clinical features alone cannot distinguish hemorrhage from ischemia 1

Anticoagulation Reversal

Rapid reversal of anticoagulation is essential to reduce hematoma expansion risk and improve outcomes 2, 3, 5, 6

Warfarin (Vitamin K Antagonists)

• Administer four-factor prothrombin complex concentrate (PCC) plus 10 mg intravenous vitamin K preferentially over fresh-frozen plasma due to faster INR correction and lower fluid load 3, 5, 6
• Target INR <1.4 within 1 hour of presentation 3

Direct Oral Anticoagulants

• For dabigatran: administer idarucizumab; if unavailable, consider hemodialysis 5, 6
• For factor Xa inhibitors (rivaroxaban, apixaban, edoxaban): administer andexanet alfa where available, or four-factor PCC (50 U/kg) or activated PCC (50 U/kg) 3, 5, 6

Heparin

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

Pre-Surgical Coagulation Targets

• Prothrombin time/activated partial thromboplastin time should be <1.5 times normal control before any neurosurgical procedure including ICP probe insertion 2
• Platelet count >50,000/mm³ is the minimum required; higher thresholds are advisable for neurosurgical operations 2

Intracranial Pressure Management

Medical Management

• Elevate head of bed to 30 degrees for patients with evidence of increased ICP 5
• Use 0.9% saline as the isotonic crystalloid of choice; avoid hypotonic solutions (Ringer's lactate, acetate, gelatins) as they exacerbate cerebral edema 3, 5
• Maintain euvolemia through repeated hemodynamic assessment, avoiding both volume overload and hypovolemia 3

Osmotherapy and Hyperventilation (Bridge Therapies Only)

• Mannitol and hyperventilation (targeting PaCO₂ 35-40 mmHg) should be used only as temporary bridges to definitive surgical evacuation in patients with impending cerebral herniation 2
• These interventions are not sufficient as standalone treatments and must not replace surgical intervention when clear indications exist 2
• Routine hyperventilation in patients not experiencing imminent herniation is linked to poorer outcomes because cerebral vasoconstriction reduces cerebral blood flow 2

External Ventricular Drainage

• External ventricular drainage is suggested for persistent intracranial hypertension despite sedation and correction of secondary brain insults 1, 2
• An external ventricular drain alone is insufficient—and may be harmful—when basal cisterns are compressed; definitive hematoma evacuation is required 3

ICP Monitoring Indications

• ICP monitoring is not required when initial non-contrast CT is normal and there are no clinical severity indicators 2
• Intraparenchymal ICP probes are preferred over intraventricular drains due to lower infection rate (≈2.5% vs 10%) and lower hemorrhage risk (0-1% vs 2-4%) 2

Neurosurgical Indications

Cerebellar Hemorrhage (Class I Recommendation)

Patients with cerebellar hemorrhage >3 cm who are deteriorating neurologically or have brainstem compression and/or hydrocephalus from ventricular obstruction should have surgical removal as soon as possible 1, 3, 5

• Immediate surgical evacuation (with or without external ventricular drain) reduces mortality compared with medical management alone 3
• Hematoma volume ≥15 mL independently predicts the necessity for surgical evacuation and mandates immediate neurosurgical consultation 3
• Delaying neurosurgical consultation in patients with hematoma ≥15 mL or any sign of brainstem compression leads to increased mortality 3

Supratentorial Hemorrhage

• Surgical evacuation of supratentorial ICH by conventional craniotomy does not improve outcomes based on the STICH trial (average time to surgery 30 hours, good outcome 26% surgical vs 24% medical, not significant) 1, 7
• Minimally invasive techniques (stereotactic infusion of urokinase, endoscopic evacuation) reduce clot burden and risk of death but increase rebleeding risk, with functional outcome not yet proven to improve 1, 7
• Decompressive craniectomy should be considered for patients with refractory intracranial hypertension after multidisciplinary discussion 2

Subdural Hematoma

• Immediate surgical evacuation is indicated when subdural hematoma thickness exceeds 5 mm AND midline shift exceeds 5 mm, or when the patient shows neurological deterioration or decreased consciousness 2
• Anisocoria, bilateral mydriasis, or other signs of brain herniation constitute an absolute indication for immediate surgical evacuation 2

ICU Admission and Monitoring

• Admit all ICH patients to a dedicated neurocritical care unit or stroke unit, as this setting is associated with lower mortality than general ICU 1, 3, 6
• Perform neurological examinations (GCS and NIH Stroke Scale) every 15 minutes until the patient stabilizes 3
• Monitor arterial blood pressure every 15 minutes until target SBP is achieved, then every 30-60 minutes for the first 24-48 hours 3
• Continuous cardiac monitoring is advised because elevated troponin levels and ECG abnormalities correlate with poorer outcomes 3

Airway Management

• Endotracheal intubation is indicated for patients with GCS ≤8, inability to protect the airway, or evidence of impending herniation 3, 5
• Maintain arterial oxygen saturation >94% to avoid hypoxia-related secondary brain injury 3
• Control ventilation with end-tidal CO₂ monitoring even during the pre-hospital period, targeting PaCO₂ 35-40 mmHg 1

Seizure Prophylaxis

Routine seizure prophylaxis is NOT recommended unless clinical or electrographic seizures are documented 3

• Antiepileptic drugs show no benefit for primary prevention of post-traumatic seizures and may worsen neurological outcomes 2
• Consider antiepileptic drugs only if specific risk factors are present, such as chronic subdural hematoma or prior epilepsy 2

Metabolic and Supportive Care

• Maintain normoglycemia; hyperglycemia is linked to worse functional outcomes 3
• Control fever—temperatures >37.5°C for ≥24 hours are associated with increased risk of ventricular extension and poor prognosis 3
• Transfuse packed red blood cells when hemoglobin falls below 7 g/dL during emergency care; consider a higher threshold for elderly patients or those with cardiovascular disease 2

Secondary Prevention and DVT Prophylaxis

• Deep venous thrombosis prophylaxis with intermittent pneumatic compression should be initiated once bleeding has stabilized 5
• Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters if the patient can be safely managed without them 1

Prognostication and Withdrawal of Care

• Early prognostication is difficult, and early do-not-resuscitate orders or withdrawal of active care should be used judiciously in the first 24-48 hours 6
• Lower admission GCS score, larger hematoma volume, presence of intraventricular hemorrhage, and hydrocephalus are the strongest predictors of 30-day mortality 3
• Predictive models may falsely suggest universally bleak outcomes because they do not account for early DNR use, which biases outcomes to appear worse than if full care was provided 1

Common Pitfalls to Avoid

• Delaying surgical intervention for "medical optimization" beyond basic resuscitation worsens prognosis in patients with acute ICH and neurological deterioration 2
• Using fresh-frozen plasma instead of PCC for warfarin reversal results in slower INR correction and excess fluid load 3
• Administering hypotonic IV fluids aggravates cerebral edema 3, 5
• Avoiding repeat imaging in high-risk patients: hematoma expansion occurs in ~38% of patients scanned within 3 hours and confers a five-fold increase in clinical deterioration 2