Intracerebral Hemorrhage

complete reference · BP targets · reversal agents · ICH score · surgical triggers · Full Card

Symptoms / Associated Sx

• Sudden focal deficit that often progresses over minutes-hours (vs the maximal-at-onset ischemic stroke), with headache, nausea/vomiting, and depressed consciousness reflecting mass effect and raised ICP. Deep (basal ganglia/thalamic) bleeds → contralateral hemiparesis, gaze palsy; pontine → pinpoint pupils, coma; cerebellar → ataxia, vomiting, danger of brainstem compression.

• Document GCS and NIHSS; both trend for the ICH score and to detect deterioration.

Neg

• Pt denies a focal deficit that fully resolved — argues against TIA (ICH does not transiently resolve; deficits persist or worsen)

• No fever, neck stiffness, or photophobia — argues against meningitis as the cause of headache + altered mental status (though a sentinel SAH can also present with stiff neck)

• POC glucose 60–400 — argues against hypoglycemic mimic (always exclude before attributing deficit to the bleed)

• No thunderclap "worst headache of life" without focal deficit and with predominantly subarachnoid blood — points toward ICH rather than aneurysmal SAH (pattern and distribution of blood on CT distinguish; CTA clarifies)

Social History (SHx)

• Hypertension and adherence (the dominant cause); anticoagulant/antiplatelet use with last dose; heavy alcohol; cocaine/sympathomimetic use (young patients).

• Prior ICH or recurrent falls; bleeding disorders; functional baseline and goals-of-care discussion (high early mortality).

Main Etiology

• Hypertensive vasculopathy — deep structures (putamen, thalamus, pons, cerebellum), the most common cause. Cerebral amyloid angiopathy — lobar bleeds in the elderly, recurrent. Anticoagulant/antiplatelet-associated. Vascular malformations (AVM, cavernoma) and aneurysms — consider in younger patients or lobar location. Brain tumor (primary or metastatic) with hemorrhage. Hemorrhagic transformation of an ischemic infarct.

RF

• Modifiable: hypertension (strongest), anticoagulation, heavy alcohol, cocaine/stimulants, smoking.

• Non-modifiable: advancing age, cerebral amyloid angiopathy, prior ICH, Asian and Black ancestry, vascular malformations.

Data

• Non-contrast head CT (immediate diagnosis — location, hematoma volume by ABC/2 method, intraventricular extension, midline shift, hydrocephalus)

• CTA head ("spot sign" predicts hematoma expansion; reveals underlying AVM, aneurysm, or tumor — especially in young or lobar bleeds)

• CBC, INR/PTT, fibrinogen (identify and quantify coagulopathy to reverse); type & screen

• POC glucose, BMP, LFTs, urine tox (mimics, cocaine, organ dysfunction)

• ECG, troponin (neurogenic cardiac changes, demand ischemia)

• ICH score (GCS 3–4=2/5–12=1/13–15=0; volume ≥30mL=1; IVH=1; infratentorial=1; age ≥80=1 — predicts 30-day mortality, do not use to justify early withdrawal alone)

DDx

Ischemic stroke (no blood on CT — the immediate fork) · subarachnoid hemorrhage (blood in cisterns/sulci, thunderclap onset) · hemorrhagic tumor (ring enhancement, edema out of proportion on contrast/MRI) · cerebral venous thrombosis with venous infarct (non-arterial territory, bilateral, dense sinus sign) · traumatic hemorrhage (history, contusion pattern, contrecoup)

Home Meds

• Stop and reverse all anticoagulants and antiplatelets immediately.

• Hold home oral antihypertensives in favor of titratable IV control acutely.

• Hold stimulants/sympathomimetics; reconcile and avoid agents that worsen platelet function.

Plan

Consults

• Neurosurgery — emergent for evacuation, EVD, or decompression decisions.

• Neurology — co-management, seizure and BP strategy.

• Neuro-interventional — if CTA reveals an aneurysm or AVM.

• ICU / neurocritical care — most ICH patients require ICU-level monitoring; ward only for small, stable, supratentorial bleeds with intact GCS.

• PT / OT / SLP — once neurologically stable.

Blood pressure

• Target SBP 130–140 mmHg (acute lowering to <140 is safe and may reduce expansion — INTERACT2; ATACH-2 showed no benefit and possible renal harm below 120, so avoid <130). Use nicardipine (Cardene) 5 mg/h IV gtt titrate to 15 mg/h, or clevidipine (Cleviprex) 1–2 mg/h titrate. Avoid large abrupt drops.

Reverse coagulopathy

• Warfarin: 4-factor PCC (Kcentra) weight/INR-based dosing PLUS vitamin K (phytonadione/Mephyton) 10 mg IV — reverse to INR <1.4.

• Dabigatran (Pradaxa): idarucizumab (Praxbind) 5 g IV.

• Apixaban/rivaroxaban (Eliquis/Xarelto): andexanet alfa (Andexxa) per protocol, or 4-factor PCC 50 U/kg if andexanet unavailable.

• Heparin: protamine sulfate. Antiplatelet/tPA-related: platelet transfusion only if thrombocytopenic or pre-procedure (routine platelets for aspirin/clopidogrel showed harm — PATCH trial).

ICP / edema

• Head of bed 30°, neck midline; maintain normocapnia and normothermia; analgesia/sedation to avoid surges.

• If herniation or rapidly rising ICP: hyperosmolar therapy — mannitol 0.5–1 g/kg IV or hypertonic (3%) saline; involve neurosurgery for EVD/ICP monitor.

Seizure / supportive

• Treat clinical or electrographic seizures — levetiracetam (Keppra) 60 mg/kg IV (max 4.5 g) load; no routine seizure prophylaxis (no outcome benefit).

• NPO until swallow screen; glucose 140–180; VTE prophylaxis with SCDs immediately, add LMWH (enoxaparin/Lovenox 40 mg SC) only after 24–48h of documented stability and no expansion.

Always

• PT / OT / SLP eval and treat — once stable, early mobilization, swallow assessment, rehab disposition.

• Trend: GCS and focal neuro checks q1h initially; repeat non-con CT at ~6h or with any neurologic decline to detect hematoma expansion; BP continuously; coags after reversal.

• Escalation triggers: GCS drop/airway compromise → intubate, ICU · hematoma expansion or new IVH on repeat CT → neurosurgery · cerebellar bleed >3 cm or brainstem compression → emergent decompression · hydrocephalus → EVD · refractory BP needing escalating gtt → ICU.

• Discharge checklist: optimized BP regimen (e.g. amlodipine, lisinopril, chlorthalidone) with home monitoring · avoid anticoagulation/antiplatelet unless compelling indication and neurology agreement on timing · alcohol/stimulant cessation · neurology + neurosurgery follow-up with repeat imaging · fall-prevention · activity guidance · return precautions (recurrent headache, deficit, decreased alertness → 911).

Red Flags — ICU / Neurosurgery

• GCS ≤8 or airway compromise → intubate, ICU.
• Cerebellar hemorrhage >3 cm, or any with brainstem compression/hydrocephalus → emergent suboccipital decompression (delaying risks fatal herniation).
• Intraventricular hemorrhage with hydrocephalus → external ventricular drain.
• Hematoma expansion (≥33% or ≥6 mL, or spot sign) → ICU, re-image, neurosurgery.
• Signs of herniation (anisocoria, posturing, Cushing reflex) → hyperosmolar therapy + emergent neurosurgery.

Senior IM Resident Pearls

• The first hours are about three things: control the BP, reverse the coagulopathy, and get neurosurgery involved. Everything else is secondary.
• SBP target is 130–140. INTERACT2 showed intensive lowering to <140 is safe; ATACH-2 found going below 120 adds renal harm without benefit. Aim for the band, not the floor.
• Reverse by the agent: warfarin → PCC + vitamin K; dabigatran → idarucizumab; Xa inhibitors → andexanet or PCC. Don't reach for FFP first — it's slow and volume-heavy compared to PCC.
• PATCH trial: transfusing platelets for antiplatelet-associated ICH worsened outcomes. Don't give platelets reflexively for aspirin/clopidogrel — reserve for thrombocytopenia or a planned procedure.
• ICH score predicts mortality but isn't destiny. Early aggressive care and avoiding self-fulfilling early DNR/withdrawal in the first 24–48h matters — guidelines caution against early care limitation.
• Cerebellar bleeds are a surgical emergency. A >3 cm cerebellar hematoma or any brainstem compression needs decompression — these patients can look stable then crash from herniation.
• No seizure prophylaxis. Treat seizures that happen; prophylactic AEDs don't improve outcomes and levetiracetam may worsen cognition.
• Common mistake: starting VTE pharmacoprophylaxis too early. SCDs from day 1, but hold chemical prophylaxis until 24–48h of stability with no expansion on repeat imaging.