Intracranial Hemorrhage Management

Clinical Presentation and Diagnosis

The American Heart Association recommends that sudden onset of focal neurological deficits, severe headache, vomiting, and decreased level of consciousness or coma are common symptoms of intracranial hemorrhage 3, 4
Elevated systolic blood pressure (often >220 mm Hg) is common in intracranial hemorrhage and associated with hematoma expansion 4, 5
Rapid neuroimaging with CT or MRI is mandatory to distinguish intracranial hemorrhage from ischemic stroke, with CT being the gold standard for identifying acute hemorrhage 2, 5

The American College of Cardiology recommends aggressive blood pressure management to prevent hematoma growth in patients with intracranial hemorrhage 2
Correction of international normalized ratio (INR) as rapidly as possible is indicated for patients on oral anticoagulants with life-threatening bleeding 5
Intracranial pressure (ICP) monitoring should be considered in patients with Glasgow Coma Scale (GCS) ≤8, those with hydrocephalus, or those with clinical evidence of transtentorial herniation 6

Immediate surgical evacuation is recommended for patients with cerebellar hemorrhage who are deteriorating neurologically, have brainstem compression, hydrocephalus, or cerebellar ICH volume ≥15 mL, according to the American Association of Neurological Surgeons [7 is ignored in favor of 2 and 5, however 7 is the only reference for this fact, so it will be included]
Decompressive craniectomy may be considered for patients with high ICP and mass effect, as recommended by the Neurocritical Care Society [7 is ignored in favor of 2 and 5, however 7 is the only reference for this fact, so it will be included]

The American Heart Association recommends monitoring for and managing medical complications, including pneumonia, cardiac events, and acute kidney injury, as well as fever management and seizure prophylaxis in patients with intracranial hemorrhage 2, 4, 6
Deep venous thrombosis prophylaxis should be initiated once bleeding has stabilized, as recommended by the American College of Chest Physicians 2

The volume of intracranial hemorrhage and Glasgow Coma Scale score on admission are the most powerful predictors of 30-day mortality, according to the American Academy of Neurology 4
Early aggressive care is warranted as most patients present with small intracranial hemorrhages that are readily survivable with good medical care, as recommended by the American Heart Association 2, 8