Hemorrhagic stroke (intracerebral)MANAGEMENT

NEUROLOGICAL PRESENTATIONS · 12 SECTIONS

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654 items

☷ Legend

01Approach to the Critical Patient/attcp68

Immediate priorities

›Time zero stabilization

›Airway protection triggers

›GCS 8 or less

›Loss of protective reflexes

›Refractory hypoxemia or hypercapnia

›Persistent vomiting with aspiration risk

›Breathing targets

›Oxygen saturation 94 to 98 percent

›PaCO2 35 to 40 mmHg if no herniation

›PaCO2 30 to 35 mmHg only as bridge for impending herniation

›Circulation priorities

›Two large bore IV lines

›Cardiac monitoring

›Temperature monitoring

›Point of care glucose

›Neurologic crisis triage

›Herniation syndrome

›Declining level of consciousness

›Unilateral fixed dilated pupil

›Extensor posturing

›Cushing response

›Immediate actions if herniation suspected

›Head of bed 30 degrees

›Neck midline

›Hyperosmolar bolus selection

›Hypertonic saline preferred if hypotension risk

›Mannitol avoided if hypotension or renal failure risk

›Emergent neurosurgery and neurocritical care activation

›Imaging first pathway

›Noncontrast CT head within minutes

›ICH confirmed

›CTA head and neck for selected patients

›Coagulopathy reversal pathway parallel to imaging

›ICH not confirmed

›Ischemic stroke pathway

›Mimic evaluation

Hemodynamic goals

›Blood pressure strategy

›Early controlled reduction to limit hematoma expansion

›SBP 150 to 220 mmHg and no contraindication

›Target SBP 140 mmHg

›Maintenance SBP 130 to 150 mmHg

›Avoid excessive lowering

›SBP less than 130 mmHg association with harm in some cohorts

›Preferred IV agents for rapid titration

›Nicardipine infusion

›Clevidipine infusion

›Labetalol bolus

›Intracranial pressure physiology

›Cerebral perfusion pressure concept

›CPP equals MAP minus ICP

›Hypotension avoidance

›ICP triggers for escalation

›Clinical herniation signs

›Hydrocephalus with IVH

›Large hematoma with midline shift

›Refractory agitation or ventilator dyssynchrony limiting care

Parallel process consults

›Early team activation

›Neurosurgery for all ICH with mass effect or IVH or posterior fossa

›Cerebellar ICH concern

›Brainstem compression

›Obstructive hydrocephalus

›ICH volume 15 mL or more

›Neurocritical care

›ICU level monitoring

›EVD consideration for IVH with hydrocephalus

›Hematology or thrombosis support

›Complex anticoagulant reversal

›Mechanical valve anticoagulation decisions

02History/hx63

Focused symptom context

›Symptom onset and course

›Last known well time

›Witnessed onset

›Wake up deficit

›Headache features

›Thunderclap quality

›Worst headache

›Vomiting

›Early forceful emesis

›Aspiration concern

›Seizure at onset

›Generalized convulsion

›Focal motor activity

›Anticoagulant or antiplatelet exposure

›Warfarin

›Dabigatran

›Rivaroxaban

›Apixaban

›Edoxaban

›Heparin

›Low molecular weight heparin

›Clopidogrel

›Ticagrelor

›Aspirin

›Etiology clues

›Hypertension history

›Poor control

›Medication nonadherence

›Cerebral amyloid angiopathy clues

›Age 55 years or more

›Prior lobar hemorrhage

›Cognitive impairment history

›Vascular malformation clues

›Prior sentinel headaches

›Known AVM or cavernoma

›Family history of AVM

›Tumor related hemorrhage clues

›Cancer history

›Subacute headache weeks

›Progressive neurologic symptoms weeks

›Sympathomimetic exposure

›Cocaine

›Amphetamines

›Decongestants

›Trauma context

›Recent fall

›Assault

›Anticoagulation with head impact

Baseline and goals

›Baseline function

›Pre event mRS estimate

›Independent

›Needs assistance

›Bedbound

›Baseline cognition

›Dementia diagnosis

›Mild cognitive impairment

›Advance care planning

›Code status knowledge

›Prior directives

›Substitute decision maker

›Values and acceptable outcomes

›Independence priority

›Longevity priority

03Physical Exam/exam50

Neurologic assessment

›Neurologic severity

›GCS components

›Eye opening category

›Verbal response category

›Motor response category

›NIHSS domains

›Level of consciousness

›Language

›Neglect

›Motor deficits

›Brainstem function

›Pupillary size and reactivity

›Unilateral dilation

›Nonreactive pupils

›Gaze deviation

›Forced gaze

›Dysconjugate gaze

›Corneal reflexes

›Absent reflex concern

›Cough and gag

›Weak reflex concern

›Herniation features

›Posturing

›Decorticate

›Decerebrate

›Respiratory pattern abnormality

›Irregular respirations

›Cushing response

›Hypertension with bradycardia

General and secondary causes

›Hemodynamic state

›Blood pressure extremes

›Severe hypertension

›Hypotension shock

›Arrhythmia

›Atrial fibrillation

›Volume status cues

›Dry mucous membranes

›Pulmonary edema

›Bleeding diathesis clues

›Petechiae or purpura

›Thrombocytopenia concern

›Mucosal bleeding

›Coagulopathy concern

›Meningismus

›Neck stiffness

›SAH consideration

›Trauma stigmata

›Scalp hematoma

›Battle sign

›Facial trauma

04Differential Diagnosis/ddx41

Intracranial hemorrhage spectrum

›Hemorrhagic stroke differential

›Primary spontaneous intracerebral hemorrhage

›ICD-10 I61.9

›SNOMED CT intracerebral hemorrhage

›Subarachnoid hemorrhage

›Thunderclap headache

›Basal cistern blood pattern

›Subdural hematoma

›Trauma association

›Crescent collection on CT

›Epidural hematoma

›Temporal bone trauma

›Lens collection on CT

›Intraventricular hemorrhage primary

›Isolated IVH on imaging

Mimics and alternate emergencies

›Acute neurologic deficits

›Ischemic stroke with early edema

›No hyperdensity consistent with blood

›Seizure with postictal deficit

›Todd paralysis

›Hypoglycemia

›Glucose low mmol/L

›CNS infection

›Encephalitis

›Meningitis

›Toxic metabolic encephalopathy

›Hypercapnia

›Hepatic encephalopathy

›Secondary ICH causes

›Cerebral venous thrombosis with hemorrhagic infarct

›Headache and papilledema

›Hemorrhagic transformation of ischemic stroke

›Recent reperfusion therapy

›Tumor bleed

›Metastasis prone lesions

›Vascular malformation rupture

›AVM

›Dural AV fistula

›Cavernous malformation

›Mycotic aneurysm rupture

›Endocarditis context

05Laboratory Tests/lt46

Initial critical labs

›Baseline safety labs

›Complete blood count for platelet count and anemia

›Platelets less than 100 x10^9/L concern for expansion and procedures

›Hemoglobin trend for concurrent bleeding

›Electrolytes and renal function

›Sodium for osmolality planning

›Creatinine for contrast and reversal choices

›Coagulation profile

›INR for warfarin effect

›aPTT for heparin effect

›Fibrinogen for massive bleeding or DIC concern

›Liver function

›Hepatic synthetic dysfunction association with coagulopathy

›Glucose mmol/L

›Hypoglycemia mimic exclusion

›Hyperglycemia association with worse outcomes

›Directed toxicology and exposure labs

›Pregnancy test in reproductive potential

›CT and medication planning

›Type and screen

›Planned surgery or large hematoma risk

›Ethanol level if intoxication suspected

›Fall risk and altered mental status

›Urine drug screen if stimulant exposure concern

›Cocaine or amphetamine associated ICH

Anticoagulant specific testing

›Warfarin assessment

›INR severity

›INR 1.5 or more clinically relevant

›INR 2.0 or more high risk expansion

›DOAC assessment

›Dabigatran

›Thrombin time elevated supportive

›Dilute thrombin time if available

›Factor Xa inhibitors

›Anti Xa activity assay if calibrated and available

›PT and aPTT insensitive and cannot exclude effect

Monitoring labs during ICU course

›Metabolic and therapy monitoring

›Serum sodium for hypertonic therapy

›Avoid rapid correction in chronic hyponatremia

›Hypernatremia risk with repeated boluses

›Serum osmolality if mannitol used

›Osmolality high risk for renal injury

›ABG or VBG if ventilated

›PaCO2 target confirmation

›Troponin if cardiac ischemia suspected

›Stress cardiomyopathy association with stroke

06Diagnostic Tests/dt76

Scoring Systems

›Severity and prognosis tools

›ICH score

›Components

›GCS 3 to 4

›GCS 5 to 12

›ICH volume 30 mL or more

›Intraventricular hemorrhage present

›Infratentorial origin

›Age 80 years or more

›Use limits

›Not for individual withdrawal of care decisions

›Communicates population risk only

›FUNC score

›Functional outcome estimation

›Age banding

›ICH volume banding

›ICH location

›GCS

›Pre ICH cognitive impairment

›Use limits

›Avoid as sole basis for goals of care

›Combine with patient values and trajectory

MRI

›MRI brain with and without contrast

›Indications

›Lobar ICH without clear hypertensive pattern

›Young patient without hypertension

›Suspicion for tumor or cavernoma

›Sequences

›GRE or SWI for microbleeds

›DWI for ischemic lesions

›FLAIR for edema and subacute blood

›Etiology markers

›Cerebral amyloid angiopathy microbleed pattern

›Cavernous malformation popcorn lesion

›Tumor enhancement and hemorrhage

›Noncontrast CT head

›Core findings

›Location classification

›Deep basal ganglia

›Thalamus

›Lobar cortex

›Brainstem

›Cerebellum

›Hematoma volume estimate

›ABC 2 method for bedside estimate

›30 mL threshold for severity scoring

›Intraventricular extension

›Hydrocephalus evaluation

›Mass effect

›Midline shift

›Cisternal effacement

›CTA head and neck

›Indications

›Lobar ICH

›Age less than 50 years

›No hypertension history

›Atypical location

›Hematoma expansion marker

›Spot sign

›Higher expansion risk

›Guides intensity of monitoring

›CT venography

›Indications

›Hemorrhagic lesion with headache and papilledema

›Atypical cortical hemorrhage

›Risk factors for cerebral venous thrombosis

Ultrasound (or US)

›Point of care ultrasound adjuncts

›Cardiac US

›Shock evaluation

›Stress cardiomyopathy pattern

›Lung US

›Aspiration pneumonitis signs

›Pulmonary edema signs

›Optic nerve sheath diameter

›Elevated ICP screening adjunct

›Not definitive for management decisions

07Disposition/dispo32

Level of care decisions

›ICU admission criteria

›Any intracerebral hemorrhage confirmed on CT

›Neuro checks frequency requirement

›Blood pressure infusion need

›Intraventricular hemorrhage

›Hydrocephalus risk

›Posterior fossa hemorrhage

›Rapid deterioration risk

›Anticoagulant associated ICH

›Reversal and rebound monitoring

›Depressed consciousness

›GCS 13 or less

›Transfer criteria

›Need for neurosurgical capability

›EVD placement

›Hematoma evacuation

›Posterior fossa decompression

›Need for neurointerventional capability

›Suspected ruptured aneurysm

›AVM evaluation

Observation and repeat imaging

›Repeat CT timing

›Clinical deterioration at any time

›Immediate CT head

›Stable but high risk expansion

›Early presentation within 6 hours

›Anticoagulant exposure

›CTA spot sign

›Repeat CT within 6 to 24 hours local protocol

›Discharge rarity

›Non ICH alternative diagnosis confirmed

›Discharge with stroke follow up

›Return precautions documented

08Treatment/t143

Blood pressure management

›IV antihypertensive strategy

›Nicardipine infusion

›Initiate 5 mg per hour

›Titrate 2.5 mg per hour every 5 to 15 minutes

›Maximum 15 mg per hour

›Clevidipine infusion

›Initiate 1 to 2 mg per hour

›Double dose every 90 seconds until near goal

›Typical maintenance 4 to 6 mg per hour

›Maximum 21 mg per hour

›Labetalol bolus

›10 to 20 mg IV over 1 to 2 minutes

›Repeat or escalate every 10 minutes

›Total 300 mg maximum typical

›Avoid nitroprusside

›ICP increase risk

›Cyanide toxicity risk

›Monitoring

›Arterial line for infusion titration

›Beat to beat pressure

›Avoid overshoot hypotension

Reversal of antithrombotics

›Warfarin associated ICH

›Four factor PCC

›Initiate 50 IU per kg if INR high or life threatening bleed

›Maximum 5000 IU typical institutional limit

›Recheck INR 15 to 30 minutes after dose

›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 management

›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

Supportive ICU care

›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

09Special Populations/sp47

Pregnancy

›Pregnancy specific considerations

›Etiology and risk context

›Preeclampsia and eclampsia association

›Severe hypertension and neurologic symptoms

›Magnesium sulfate for eclampsia pathway if seizures and obstetric concern

›Imaging

›CT head acceptable when maternal stabilization priority

›Shielding when feasible

›MRI without gadolinium preferred for etiologic workup when stable

›Medication safety

›Nicardipine and labetalol commonly used

›Avoid ACE inhibitors

›Anticoagulant reversal risk benefit individualized

›Obstetrics coordination

›Fetal monitoring based on gestational age

›Delivery planning only after maternal stabilization

›Transfer to center with neurocritical and obstetric ICU when possible

Geriatric

›Older adult considerations

›Cerebral amyloid angiopathy prevalence

›Lobar ICH recurrence risk

›Microbleed burden on MRI as risk marker

›Antithrombotic restart decisions individualized

›Delirium prevention

›Avoid oversedation

›Hearing and vision aids

›Sleep promotion and reorientation

›Frailty and goals of care

›Baseline function and cognition documentation

›Prognosis communication

›Time limited trials of therapy when uncertain

Pediatrics

›Pediatric intracerebral hemorrhage

›Etiology pattern

›AVM more common relative to adults

›Coagulopathy and hematologic disorders

›Tumor hemorrhage consideration

›Imaging and sedation

›CT head for rapid diagnosis

›CTA or MRA for vascular lesion

›MRI for definitive etiologic assessment when stable

›Weight based therapy

›Hypertonic saline dosing per kg

›Mannitol dosing per kg

›Antiseizure dosing per kg per local formulary

›Child protection context

›Nonaccidental trauma consideration

›Multidisciplinary safeguarding involvement

›Detailed documentation

10Background/b49

Epidemiology

›Epidemiologic context

›ICH proportion of strokes

›Approximately 10 to 15 percent of all strokes in many regions

›Higher proportion in some Asian populations

›Case fatality high compared with ischemic stroke

›Major risk factors

›Chronic hypertension

›Deep hemispheric hemorrhage association

›Prevention through long term BP control

›Cerebral amyloid angiopathy

›Lobar hemorrhage association

›Recurrence risk higher than deep ICH

›Antithrombotic therapy

›Warfarin and DOAC exposure increases severity and expansion risk

›Reversal time critical

Pathophysiology

›Mechanisms of injury

›Primary bleed and mechanical disruption

›Tissue destruction at onset

›Mass effect and raised ICP

›Herniation risk

›Hematoma expansion

›Highest risk early hours

›Associated with worse outcomes

›Target for early BP control and reversal

›Secondary brain injury

›Perihematomal edema

›Inflammatory cascade

›ICP elevation days after onset

›Intraventricular extension

›Hydrocephalus development

›ICP elevation

›EVD role

Therapeutic Considerations

›Evidence anchored priorities

›Time to treatment importance

›Early BP control reduces hematoma growth signal in trials

›Functional benefit modest and dependent on safe target range

›Avoid overshoot hypotension

›Anticoagulant reversal benefit

›Rapid INR normalization reduces ongoing bleeding risk

›PCC faster than FFP for warfarin reversal

›Thrombosis risk balanced against catastrophic bleeding

›Neurosurgical intervention selection

›Cerebellar evacuation reduces mortality in selected patients

›Supratentorial surgery functional benefit uncertain overall

›Minimally invasive approaches evolving and center dependent

›Prognostication ethics

›Early limitations of care can create self fulfilling prophecy

›Delayed prognostication reasonable when uncertainty

›Shared decision making and time limited trials

11Patient Discharge Instructions/pdi22

copy discharge instructions

›Intracerebral hemorrhage aftercare

›Medication safety

›No NSAIDs unless explicitly prescribed

›No alcohol binges

›No illicit stimulants

›Blood pressure plan

›Home BP monitoring if available

›Take BP medications exactly as prescribed

›Primary care or stroke clinic follow up within 1 to 2 weeks if discharged

›Activity guidance

›No driving until cleared

›Avoid heavy lifting until cleared

›Fall prevention strategies

›Return to ED immediately for

›New or worsening weakness

›New speech trouble

›New severe headache

›Repeated vomiting

›Seizure

›Confusion or fainting

›Vision loss

›Any rapid decline

12References/r17

Clinical guidelines and landmark evidence

›Core guidelines

›AHA ASA guideline for spontaneous intracerebral hemorrhage 2022

›Blood pressure acute management recommendations

›Antiplatelet and platelet transfusion recommendations

›Neurocritical Care Society and Society of Critical Care Medicine guideline for reversal of antithrombotics in intracranial hemorrhage 2016

›Warfarin reversal with PCC and vitamin K

›DOAC reversal strategies

›Key trials and evidence base

›INTERACT2 trial intensive BP lowering in acute ICH

›Functional outcome signal with SBP target near 140 mmHg

›Safety considerations for very low SBP

›ATACH II trial intensive BP lowering in acute ICH

›No clear functional benefit with very intensive targets

›Renal adverse event signal

›PATCH trial platelet transfusion in antiplatelet associated ICH

›Worse outcomes with platelet transfusion in nonsurgical patients

›Avoid routine platelet transfusion

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.