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Management of Intracerebral Hemorrhage
Various blood products on Sagittal MRI of an intraparenchymal hemorrhage.
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Management of Intracerebral Hemorrhage

Please refer to the Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Stroke* from 2015 for complete recommendations.
    • What follows are some helpful considerations for clinicians from that review; this information is not exhaustive and is simply designed for efficient review.
Emergency Diagnosis and Assessment
  • Perform a baseline severity score.
  • Perform non-contrast CT or MRI (to distinguish ischemic stroke from ICH).
  • Advanced imaging modalities can be useful to help determine risk for hematoma expansion (especially CTA and contrast-enhanced CT) and evaluate for underlying structural lesions, including vascular malformations and brain tumors (CTA, CT venography, contrast-enhanced CT, contrast-enhanced MRI, MRA, and MR venography).
  • Reverse coagulopathies
    • Provide appropriate factor replacement therapy in coagulation factor deficient patients.
    • Provide platelets in patients with severe thrombocytopenia.
  • Patients on vitamin K antagonists (VKAs), such as warfarin, with and elevated INR, perform the following:
    • Withhold further VKA administration.
    • Provide vitamin K–dependent factor replacement to correct the INR; PCCs (plasma-derived factor concentrates) are generally preferred over FFP (fresh frozen plasma) because PCCs can rapidly normalize the INR (within minutes).
    • Provide intravenous vitamin K (5-10mg).
  • Factor Xa Inhibitors and Direct Thrombin Inhibitors
    • Generally best to consult a hematologist to determine best approach to reversal, as many strategies exist.
  • In spontaneous ICH in patients receiving intravenous heparin infusion, it is recommended to give protamine sulfate IV.
    • Dosing is 1 mg per 100 U of heparin BUT adjust dose based on time elapsed since discontinuation of heparin infusion and max dose is 50mg.
    • Similar dosing can be used in patients who are receiving low-molecular-weight heparin.
  • Provide intermittent pneumatic compression for prevention of venous thromboembolism.
    • Graduated compression stockings are not beneficial to reduce DVT or improve outcome.
    • After 1 to 4 days from onset of bleeding and when bleeding has clearly ceased, low-dose subcutaneous low-molecular-weight heparin or unfractionated heparin may be considered for prevention of venous thromboembolism in patients with lack of mobility.
  • In ICH patients with symptomatic DVT or PE, provide either systemic anticoagulation or IVC filter placement.
    • Time from hemorrhage onset, hematoma stability, cause of hemorrhage, and overall patient condition are all factors that can help in deciding between anticoagulation and IVC filter.
Hypertension Management
  • Understanding that high SBP is in ICH is associated with greater hematoma expansion, neurological deterioration, and death and dependency, it is generally accepted that an SBP target of <140 mm Hg in the early management of ICH is advisable (if the present SBP is < 220 mm Hg).
    • This recommendation is based on the INTERACT 2 trial, which demonstrated significantly better functional recovery from intensive BP treatment (SBP <140 mmg HG) vs standard treatment (SBP <180 mm Hg).
    • For ICH patients with a presenting SBP >220 mm Hg, aggressive reduction of BP is still recommended but the exact target BP is undefined.
General Care
  • Monitor and treat hyperglycemia
  • Monitor and treat fever
  • Monitor for dysphagia
  • Monitor for myocardial ischemia
  • Monitor and treat seizures
    • Consider continuous EEG monitoring in patients with reduced level of arousal out of proportion to the degree of brain injury.
    • Prophylactic antiseizure medication is not recommended.
ICP Monitoring and Management
  • Ventricular drainage for hydrocephalus when clinically indicated.
  • Do NOT administer corticosteroids routinely for elevated ICP from ICH.
Indications for Surgical Treatment of ICH
  • Cerebellar hemorrhage with progressive deterioration OR with either:
    • Brainstem compression
    • Hydrocephalus from ventricular obstruction
  • Supratentorial evacuation is typically reserved for deteriorating patients.
Reference
HEMPHILL, J. C., 3RD et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke, v. 46, n. 7, p. 2032-60, Jul 2015. ISSN 0039-2499.

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