Management of Intracranial Hemorrhage

Initial Assessment and Management

Assess pupils and Glasgow Coma Scale motor score to determine severity of brain damage, focusing on patients with severe brain damage, as recommended by the American College of Emergency Physicians 1
Maintain cerebral perfusion pressure ≥60 mmHg when ICP monitoring is available to ensure adequate blood flow to the brain, as recommended by the American Heart Association 1
Obtain urgent neuroimaging, such as non-contrast head CT, to confirm ICH and assess hematoma size, location, and presence of intraventricular extension, and perform a standardized severity score as part of initial evaluation in patients with ICH 2, 3, 4
Monitor baseline glucose levels to avoid hyperglycemia and hypoglycemia, and manage patients with ICH in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise 2

Immediately withhold vitamin K antagonists (warfarin) and administer prothrombin complex concentrate (PCC) based on INR, with specific dosing guidelines:
INR PCC Dose
2-3.9 25 units/kg
4-5.9 35 units/kg
>6 50 units/kg
Administer idarucizumab for dabigatran and andexanet alfa for factor Xa inhibitors (rivaroxaban, apixaban, edoxaban), as recommended by the American Stroke Association 6

Target systolic blood pressure of 140 mmHg within 1 hour of treatment initiation in patients with ICH, with a strength of evidence level of IIa, and avoid rapid decreases of >60 mmHg in the first hour, as recommended by the American Heart Association 6, 7, 8
Maintain systolic blood pressure 130-150 mmHg during the maintenance phase (24-48 hours), and avoid systolic blood pressure <130 mmHg, as recommended by the American Heart Association 6, 7, 8
Use intravenous nicardipine and labetalol as first-line agents for blood pressure control in patients with ICH, due to their smooth and titratable action 7, 9

Consider simultaneous multisystem surgery for patients requiring both intervention for life-threatening hemorrhage and emergency neurosurgery, as recommended by the World Society of Emergency Surgery 1
Perform decompressive craniectomy in patients with large hemispheric hemorrhages causing significant mass effect and midline shift, with a strength of evidence level of III, and consider the decision based on a risk-benefit discussion between the multidisciplinary medical team and the patient surrogate, with a strength of evidence level of IIb 3
Surgically evacuate cerebellar hemorrhages >3 cm or those causing brainstem compression or hydrocephalus, as recommended by the American Heart Association/American Stroke Association 2, 4
Consider ventricular drainage for hydrocephalus, especially in patients with decreased level of consciousness, as recommended by the American Heart Association/American Stroke Association 2, 4

Apply intermittent pneumatic compression devices as soon as possible to prevent venous thromboembolism in patients with ICH, with a strength of evidence level of I, as recommended by the American College of Cardiology 6
Consider low-dose subcutaneous low-molecular-weight heparin or unfractionated heparin for prevention of venous thromboembolism only after documentation of cessation of bleeding, typically 1-4 days from onset, with a strength of evidence level of IIa, as recommended by the Society of Critical Care Medicine 6, 10, 11
Avoid inferior vena cava filters as routine thromboprophylaxis, as recommended by the Society of Critical Care Medicine 11

Perform complete blood count, coagulation studies (PT/aPTT), and screening for underlying conditions, as recommended by the American Heart Association 4
Monitor for elevated blood pressure, which is associated with hematoma expansion and poor outcomes, and discontinue thrombolytic agents, reverse anticoagulation, and provide aggressive supportive care to limit hematoma expansion and improve survival in patients with ICH 6, 2, 12

Avoid administration of tPA for new ischemic events in patients with recent ICH, with a strength of evidence level of III, and discontinue antiplatelet agents when intracranial hemorrhage is present or suspected, as recommended by the American Heart Association and Society of Critical Care Medicine 3, 13
Do not administer corticosteroids for treatment of elevated ICP in ICH, as recommended by the American Heart Association/American Stroke Association 2
Consider ICP monitoring in patients with GCS score ≤8, clinical evidence of transtentorial herniation, or significant IVH, and maintain cerebral perfusion pressure (CPP) at 50-70 mmHg if ICP monitoring is in place, as recommended by the American Heart Association/American Stroke Association 2
Treat clinical seizures in patients with ICH with antiseizure medications, and electrographic seizures found on EEG in patients with altered mental status, and perform formal screening for dysphagia before initiating oral intake to reduce the risk of pneumonia in patients with ICH 2
Use isotonic fluids (0.9% saline) to maintain hydration, and avoid hypotonic solutions and synthetic colloids in early management, as recommended by the American Society of Anesthesiologists 14