›Vitamin K
›Initiate 10 mg IV
›Slow infusion to reduce reactions
›Repeat INR in 6 to 12 hours
›Dabigatran associated ICH
›Idarucizumab
›Initiate 5 g IV total
›Two 2.5 g doses back to back
›Consider repeat dosing if rebound with ongoing bleeding and labs suggest effect
›Factor Xa inhibitor associated ICH
›Andexanet alfa if available
›Dosing per agent and last dose timing
›High dose regimen criteria
›Recent high dose exposure
›Low dose regimen criteria
›Remote exposure or lower dose
›Four factor PCC alternative
›Initiate 50 IU per kg
›Maximum per institutional protocol
›Thrombosis risk discussion and monitoring
›Heparin associated ICH
›Protamine
›Initiate dose based on heparin received in prior hours
›Repeat dosing based on aPTT and ongoing bleeding
›Hypotension and anaphylaxis risk precautions
›Antiplatelet associated ICH
›Platelet transfusion
›Avoid in nonsurgical aspirin associated ICH
›Consider only for emergent neurosurgery
›Neurosurgery directed target platelet count
›Desmopressin
›Initiate 0.3 mcg per kg IV once for platelet dysfunction concern
›Hyponatremia monitoring
›Fluid restriction consideration
›Thrombocytopenia
›Platelet transfusion thresholds
›Initiate to 100 x10^9/L or more if neurosurgery planned
›Initiate to 50 x10^9/L or more if active bleeding without surgery
›Repeat counts after transfusion
Intracranial pressure and cerebral edema
›Nonpharmacologic measures
›Head of bed 30 degrees
›Neck midline
›Avoid jugular venous compression
›Sedation and analgesia
›Ventilator synchrony
›Avoid coughing and Valsalva
›Hyperosmolar therapy
›Hypertonic saline 3 percent bolus
›Initiate 2 mL per kg IV bolus
›Repeat based on exam and sodium target
›Serum sodium checks every 4 to 6 hours during escalation
›Hypertonic saline 23.4 percent bolus
›Initiate 30 mL IV via central access
›Use for impending herniation
›Monitor sodium and hemodynamics closely
›Mannitol
›Initiate 0.25 to 1 g per kg IV bolus
›Avoid if hypotension or renal failure
›Serum osmolality monitoring if repeated dosing
›CSF diversion
›External ventricular drain
›IVH with obstructive hydrocephalus
›Neurologic decline from hydrocephalus
›ICP monitoring optional adjunct per center
›Seizure treatment
›Benzodiazepine abortive
›Lorazepam 0.1 mg per kg IV
›Maximum 4 mg per dose
›Repeat once if needed
›Maintenance antiseizure
›Levetiracetam
›Initiate 1000 to 1500 mg IV load
›Maintenance 500 to 1500 mg twice daily
›Renal adjustment
›Prophylaxis approach
›No routine prophylaxis for all ICH
›Consider for lobar hemorrhage with cortical involvement
›Consider continuous EEG in unexplained encephalopathy
›Nonconvulsive seizures risk
›Glucose management
›Moderate target range
›7.8 to 10.0 mmol/L
›Avoid hypoglycemia
›Insulin infusion per ICU protocol if persistent hyperglycemia
›Temperature management
›Normothermia
›Treat fever source
›Antipyretics
›Cooling measures if refractory
›Venous thromboembolism prevention
›Intermittent pneumatic compression
›Initiate day of admission
›Continuous use except skin checks
›Avoid as sole measure if prolonged immobility
›Pharmacologic prophylaxis timing
›Low dose UFH or LMWH
›Initiate 24 to 48 hours after stable repeat CT per protocol
›Hold if expansion or planned surgery
Surgical and procedural interventions
›Posterior fossa hemorrhage
›Immediate surgical evacuation recommendation in selected patients
›Neurologic deterioration
›Brainstem compression
›Obstructive hydrocephalus
›Supratentorial hematoma evacuation
›Craniotomy considerations
›Life threatening mass effect
›Clinical deterioration with large hematoma
›Location accessible and surgical candidate
›Minimally invasive surgery considerations
›Selected patients with moderate to large ICH
›Early time window
›Center expertise dependent
›Decompressive craniectomy
›Refractory elevated ICP with large hematoma and midline shift
›Mortality reduction possible
›Functional benefit uncertain
›Shared decision making emphasized