Home

Search

Pathway AI

Account ⋅ Sign Out

Table of contents

Intracerebral hemorrhage

Key sources
The following summarized guidelines for the evaluation and management of intracerebral hemorrhage are prepared by our editorial team based on guidelines from the European Society of Hypertension (ESH 2023), the American Heart Association (AHA/ASA 2022), the Canadian Stroke Best Practice Recommendations (CSBPR 2021), the European Stroke Organisation (ESO 2021; 2019; 2017; 2014), the European Society of Intensive Care Medicine (ESICM 2021), the Neurocritical Care Society (NCS 2020), and the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018).
1
2
3
4
5
6
7
8
9
10

Guidelines

1.Classification and risk stratification

Severity grading: obtain a baseline measurement of overall hemorrhage severity as part of the initial evaluation of patients with spontaneous ICH to provide an overall measure of clinical severity.
B
Show 2 more
Create free account

2.Diagnostic investigations

Initial evaluation
As per AHA 2022 guidelines:
Elicit focused medical history, perform a physical examination, and obtain routine laboratory tests (such as CBC, PT/INR/PTT, creatinine/eGFR, glucose, cardiac troponin, toxicology screen, and inflammatory markers) on hospital admission in patients with spontaneous ICH to help identify the type of hemorrhage, active medical issues, and risk of unfavorable outcomes.
B
Obtain an ECG in all patients on hospital admission.
B

More topics in this section

  • Diagnostic imaging (CT/MRI)

  • Diagnostic imaging (CTA/MRA)

  • Diagnostic imaging (DSA)

3.Medical management

Prehospital care: as per AHA 2022 guidelines, use stroke recognition and severity tools by dispatch personnel and first responders in patients with sudden onset of neurological symptoms or signs attributable to potential spontaneous ICH to identify potential stroke and facilitate rapid transport to reduce time to diagnosis and treatment.
B
Show 4 more

More topics in this section

  • Setting of care

  • Management of BP

  • Management of blood glucose

  • Management of coagulopathy (anticoagulant reversal)

  • Management of coagulopathy (antiplatelet reversal)

  • Management of coagulopathy (rFVIIa)

  • Management of coagulopathy (tranexamic acid)

  • Management of ICP

  • Management of seizures

  • Management of fever

  • Management of comorbidities

  • Withdrawal of care

4.Inpatient care

Serial clinical assessment
As per AHA 2022 guidelines:
Obtain frequent neurological assessments (including GCS) by emergency department nurses in the early hyperacute phase of care to assess change in status, neurological examination, or level of consciousness in patients with spontaneous ICH.
B
Consider obtaining frequent neurological assessments in the ICU and stroke unit for up to 72 hours of admission to detect early neurological deterioration in patients with spontaneous ICH.
C

More topics in this section

  • Serial imaging assessment

  • Thromboprophylaxis

  • Prevention of inpatient complications

5.Nonpharmacologic interventions

Lifestyle modifications
Consider offering lifestyle modifications to reduce BP in patients with spontaneous ICH.
C
Advise avoiding heavy alcohol consumption to reduce hypertension and risk of ICH in patients with spontaneous ICH.
B

6.Surgical interventions

Indications for surgery, supratentorial hemorrhage: consider performing minimally invasive hematoma evacuation with endoscopic or stereotactic aspiration with or without thrombolytic use to reduce mortality
C
, but not for improving functional outcomes, in patients with a GCS scores of 5-12 and supratentorial ICH of > 20-30 mL volume. Consider performing minimally invasive hematoma evacuation over conventional craniotomy to improve functional outcomes in these patients considered for hematoma evacuation.
C
Show 3 more

More topics in this section

  • Indications for surgery (cerebellar hemorrhage)

  • Indications for surgery (intraventricular hemorrhage)

7.Specific circumstances

Patients with concomitant venous thromboembolism
Consider placing a temporary retrievable filter as a bridge until anticoagulation in patients with acute spontaneous ICH and proximal DVT not yet candidates for anticoagulation.
C
Consider delaying UFH or LMWH for 1-2 weeks after the onset of ICH in patients with acute spontaneous ICH and proximal DVT or PE.
C

8.Patient education

Caregiver counseling
Consider providing psychosocial education for the caregiver to increase patients' activity level and participation and/or QoL.
C
Consider providing practical support and training for the caregiver to improve patients' standing balance.
C

9.Preventative measures

Primary prevention: consider incorporating any available MRI results demonstrating cerebral microbleed burden or cortical superficial siderosis to inform shared decision-making about stroke prevention treatment plans when considering primary prevention of ICH.
C

More topics in this section

  • Secondary prevention

10.Follow-up and surveillance

Stroke rehabilitation: offer multidisciplinary rehabilitation including regular team meetings and discharge planning to improve functional outcomes and reduce morbidity and mortality in patients with spontaneous ICH.
A
Show 5 more

More topics in this section

  • Management of neurobehavioral complications

  • Resumption of antithrombotics

  • Follow-up imaging

11.Quality improvement

Public health measures
Design and implement stroke public education programs for diverse populations focused on early recognition and the need to seek emergency care rapidly to reduce time to diagnosis and treatment.
B
Develop regional systems of stroke care so all potentially beneficial therapies can be made available when appropriate as rapidly as possible‚ including, at a minimum healthcare facilities providing initial spontaneous ICH care including diagnosis and treatment, and healthcare facilities with neurocritical care and neurosurgical capabilities.
B