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Symptom
dx.
Clinical Reference
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Interpretation guide
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Intracerebral Hemorrhage
Cardiovascular Presentations
Abdominal aortic aneurysm
Acute coronary syndrome (NSTEMI)
Acute coronary syndrome (STEMI)
Acute decompensated heart failure
Acute limb ischemia
Acute mesenteric ischemia
Aortic dissection
Aortic stenosis
Atrial fibrillation and flutter
Bradyarrhythmia and heart block
Cardiac arrest
Deep vein thrombosis
Myocarditis
Pericarditis
Pulmonary embolism
Stable angina
Superficial thrombophlebitis
Superior vena cava syndrome
Supraventricular tachycardia
Syncope (cardiogenic)
Unstable angina
Ventricular tachycardia
Respiratory Presentations
Acute bronchitis
Acute respiratory failure
Aspiration pneumonia
Asthma exacerbation
Bronchiolitis
Community-acquired pneumonia
COVID-19 pneumonia
COPD exacerbation
Croup
Croup (laryngotracheobronchitis)
Epiglottitis
Hemothorax
Hospital-acquired pneumonia
Pleural effusion
Pneumothorax (traumatic)
Pulmonary contusion
Spontaneous pneumothorax
Neurological Presentations
Bell's palsy
Benign paroxysmal positional vertigo
Brain abscess
Cauda equina syndrome
Cervical radiculopathy
Concussion (mild traumatic brain injury)
Encephalitis
Guillain-Barré syndrome
Hemorrhagic stroke (intracerebral)
Ischemic stroke
Lumbar radiculopathy
Malignant spinal cord compression
Migraine
Peripheral neuropathy (acute)
Retropharyngeal abscess
Schizophrenia (acute exacerbation)
Seizure (breakthrough:known epilepsy)
Seizure (first-time)
Spinal cord injury
Status epilepticus
Subarachnoid hemorrhage
Tension headache
Transient ischemic attack
Traumatic brain injury (moderate-severe)
Vestibular neuritis
Viral meningitis
Gastrointestinal Presentations
Acute appendicitis
Acute cholecystitis
Acute diverticulitis
Acute pancreatitis
Anal fissure
Choledocholithiasis and cholangitis
Clostridioides difficile colitis
Gastritis
Gastroenteritis (viral and bacterial)
Gastroesophageal reflux disease
Incarcerated or strangulated hernia
Inflammatory bowel disease flare
Large bowel obstruction
Lower GI hemorrhage
Peptic ulcer disease
Perforated viscus
Small bowel obstruction
Upper GI hemorrhage
Genitourinary and Reproductive Presentations
Acute prostatitis
Acute urinary retention
Ectopic pregnancy
Epididymitis
Orchitis
Ovarian torsion
Paraphimosis
Pelvic inflammatory disease
Priapism
Pyelonephritis
Renal laceration
Ruptured ovarian cyst
Testicular torsion
Tubo-ovarian abscess
Urinary tract infection (uncomplicated)
Urolithiasis (renal colic)
Vaginal bleeding (non-pregnant)
Infectious Disease Presentations
Acute sinusitis
Acute tonsillitis
Acute upper respiratory infection
Animal bite
Bacterial meningitis
Cellulitis
Conjunctivitis (bacterial)
Dental abscess
Endocarditis
Febrile neutropenia
Fournier gangrene
Hand-foot-mouth disease
Hepatitis (acute)
Herpes zoster
HIV-related illness
Human bite
Impetigo
Infected diabetic foot ulcer
Infectious mononucleosis
Influenza
Necrotizing fasciitis
Osteomyelitis
Otitis externa
Parasitic infection
Periorbital cellulitis
Peritonsillar abscess
Scabies
Sepsis
Septic arthritis
Spontaneous bacterial peritonitis
Tick-borne illness (Lyme disease)
Tinea infection
Tuberculosis
Viral exanthem
Wound infection
Trauma Presentations
Achilles tendon rupture
ACL and mceniscus tear
Ankle fracture
Ankle sprain
Burn
Calcaneus fracture
Cervical spine fracture
Clavicle fracture
Dental avulsion
Distal radius fracture
Drowning
Elbow fracture and dislocation
Electrical injury
Facial bone fracture
Facial laceration
Femur fracture
Fingertip amputation
Forearm fracture (radius and ulna)
Frostbite
Hand:finger laceration
Heat exhaustion
Heat stroke
Hip fracture
Humeral shaft fracture
Knee dislocation
Knee sprain
Lightning injury
Mandible fracture
Metacarpal fracture
Metatarsal fracture
Muscle strain
Nasal fracture
Non-accidental trauma
Orbital fracture
Patella fracture
Phalanx fracture (finger)
Proximal humerus fracture
Pulmonary contusion
Rib fracture
Rotator cuff tear (acute traumatic)
Scalp laceration
Scaphoid fracture
Shoulder dislocation
Skull fracture
Splenic laceration
Sternal fracture
Supracondylar pediatric fracture
Tendon laceration (hand:wrist)
Thoracic and lumbar spine fracture
Tibia:fibula fracture
Tibial plateau fracture
Toe fracture
Traumatic epistaxis
Traumatic hyphema
Toxicologic Presentations
Acetaminophen toxicity
Alcohol intoxication
Alcohol withdrawal
Anticholinergic toxicity
Anticoagulant overdose
Benzodiazepine overdose
Benzodiazepine:sedative overdose
Beta-blocker and calcium channel blocker toxicity
Carbon monoxide poisoning
Caustic ingestion
Digoxin toxicity
Drug eruption
Foreign body ingestion
Opioid intoxication
Opioid overdose
Opioid withdrawal
Organophosphate
Salicylate toxicity
Serotonin syndrome
Stimulant intoxication (cocaine, methamphetamine)
Tricyclic antidepressant overdose
Psychiatric Presentations
Acute anxiety
Acute psychosis
Agitation:behavioral emergency
Bipolar disorder
Conversion disorder
Major depressive episode
Neuroleptic malignant syndrome
Suicidal ideation and attempt
Musculoskeletal and Rheumatologic Presentations
Acute low back pain (mechanical)
Bursitis
Cervical radiculopathy
Costochondritis
Gout (acute)
Lumbar radiculopathy
Pseudogout
Tendinitis
Dermatology Presentations
Acute eczema (Eczema acute flare)
Allergic contact dermatitis
Erythema multiforme
Henoch-Schönlein purpura
Pressure injury
Psoriasis (acute flare)
Stevens-Johnson syndrome
Toxic epidermal necrolysis
Urticaria (acute)
Environmental and Exposure Presentations
Envenomation (snake, spider, insect)
High-altitude illness
Hypothermia
Hematologic and Oncologic Presentations
Acute chest syndrome
Coagulopathy
Hyperviscosity syndrome
Sickle cell crisis (vaso-occlusive)
Symptomatic anemia
Thrombocytopenia (severe)
Tumor lysis syndrome
Pediatric-Specific Presentations
Bronchiolitis
Croup
Emergency delivery
Febrile seizure
Kawasaki disease
Neonatal jaundice
Neonatal sepsis
Nursemaid's elbow
Pediatric fever 0 to 28 days
Pediatric fever 29 to 60 days
Pediatric fever 61 to 90 days
Pyloric stenosis
Slipped capital femoral epiphysis
Intussusception
Endocrine and Metabolic Presentations
Adrenal crisis
Diabetic ketoacidosis
Hypercalcemia
Hyperosmolar hyperglycemic state
Hypertensive emergency
Hypertensive urgency
Hypoglycemia
Myasthenia gravis crisis
Myxedema coma
Severe hyperkalemia
Severe hyponatremia
Thyroid storm
ENT and Maxillofacial Presentations
Acute laryngitis
Acute otitis media
Acute pharyngitis
Cerumen impaction
Epistaxis (anterior)
Nasal foreign body
Otitis externa
Tympanic membrane perforation
Ophthalmologic Presentations
Acute angle-closure glaucoma
Central retinal artery occlusion
Chemical eye injury
Corneal abrasion
Corneal ulcer
Globe rupture
Ocular foreign body
Orbital cellulitis
Retinal detachment
Obstetric Presentations
Hyperemesis gravidarum
Painful vaginal bleeding in pregnancy
Placenta previa
Placental abruption
Preeclampsia:eclampsia
Preterm labor
Threatened:inevitable:incomplete abortion
Systemic and Miscellaneous Presentations
Anaphylaxis
Angioedema
Cannabis-induced hyperemesis
Intracerebral Hemorrhage
POCUS
Procedures
Calculators
Resuscitation
ECG Guide
Back
Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Immediate stabilization
Airway threats
▶
GCS 8 or below — proceed to definitive airway
▶
Rapid sequence intubation
Pre-oxygenate to SpO2 100% before laryngoscopy
Inability to protect airway with vomiting or secretions
▶
Suction ready at bedside
Semi-recumbent positioning if not contraindicated
Oxygenation target SpO2 94% to 99%
▶
Avoid hypoxia — worsens secondary injury
Avoid hyperoxia — vasoconstriction risk
Hemodynamic targets
Blood pressure management
▶
Presentation SBP 150 to 220 mmHg — target SBP 140 mmHg within 1 hour
▶
Smooth sustained lowering preferred
Avoid SBP below 130 mmHg — harmful
Presentation SBP above 220 mmHg — cautious reduction to 160 to 180 mmHg
▶
Avoid aggressive drops
Minimize variability; drops exceeding 60 mmHg within 1 hour are harmful
Preferred IV agents
▶
Nicardipine 5 mg/h IV infusion, titrate by 2.5 mg/h every 5 to 15 minutes, max 15 mg/h
Labetalol 10 to 20 mg IV bolus then infusion
Avoid venous vasodilators — nitroglycerin contraindicated
Monitoring bundle
▶
Continuous cardiac monitoring — ECG abnormalities in 56 to 96% of ICH patients
▶
QTc prolongation most common (19 to 67%)
ST changes and cerebral T waves
Arterial line for accurate BP titration
▶
Intra-arterial monitoring preferred when on infusion
Hourly BP targets documented
Continuous pulse oximetry
▶
Frequent neurological reassessment
GCS trend every 15 to 30 minutes initially
Team activation and consults
Immediate neurology and neurosurgery notification
▶
Cerebellar hemorrhage over 3 cm or over 15 mL
▶
Emergent surgical consultation
EVD consideration for obstructive hydrocephalus
Supratentorial ICH over 20 to 30 mL with GCS 5 to 12
▶
Minimally invasive surgery candidate discussion
Conventional craniotomy has not shown clear benefit
Hydrocephalus with IVH — EVD placement
Anticoagulation reversal — do not wait for full lab results
▶
Warfarin with INR 1.4 or above — 4-factor PCC plus IV vitamin K 10 mg
▶
FFP inferior; use only if PCC unavailable
Class I recommendation AHA/ASA 2022
Dabigatran — idarucizumab 5 g IV
▶
If unavailable, aPCC or 4-factor PCC plus or minus renal replacement
Class I recommendation
Factor Xa inhibitors — 4-factor PCC or aPCC
▶
Andexanet alfa withdrawn from U.S. market due to unresolved safety concerns
Heparin or LMWH — protamine sulfate
Antiplatelet-associated ICH — no platelet transfusion unless emergency surgery required
▶
PATCH trial — platelet transfusion doubled mortality
Bundle of care — INTERACT3 approach within 6 hours
▶
Simultaneous intensive BP lowering plus glucose control plus antipyrexia plus reversal
▶
Improved functional outcomes at 6 months
Class IIa recommendation
Key decision points
Herniation signs — immediate neurosurgical escalation
▶
Unilateral pupil dilation — transtentorial herniation
▶
Hyperventilation to PaCO2 35 mmHg as bridge
Mannitol 1 g/kg IV or hypertonic saline 23.4% 30 mL IV
Cushing triad — hypertension, bradycardia, irregular respirations
▶
Impending herniation — immediate action
Hematoma expansion risk — occurs in approximately 33% within first hours
▶
Spot sign on CTA — active extravasation predictor
▶
Target BP reduction urgency increases
Early CT repeat at 6 hours in high expansion risk patients
History
Onset and symptom characterization
Time of symptom onset or last known normal
▶
Critical for guiding acute interventions
Symptom evolution over minutes (not instantaneous as in embolic stroke)
Core symptom profile
▶
Acute-onset focal neurological deficit
▶
Hemiplegia or hemisensory loss
Aphasia or dysarthria
Headache
▶
Present in subset but absence does not exclude ICH
Thunderclap pattern raises subarachnoid concern
Nausea and vomiting
▶
Raised intracranial pressure sign
Altered consciousness
▶
GCS 8 or below in high-volume hemorrhage
Symptom progression
▶
Worsening over first hours typical — distinguishes from ischemic stroke
▶
Approximately 25% deteriorate in transport
Approximately 25% deteriorate in ED
Seizure at onset
▶
More common than in ischemic stroke
Alarm features in history
Rapid neurological deterioration
▶
Hematoma expansion in approximately 1 in 3 patients
GCS decline of 2 or more points
Coma or motor posturing
▶
Massive supratentorial hemorrhage
Brainstem involvement or acute hydrocephalus
Neck stiffness
▶
Intraventricular extension with subarachnoid blood
Medication and substance history
Anticoagulants and antiplatelets
▶
Warfarin — time of last dose and recent INR
DOACs — rivaroxaban, apixaban, dabigatran, edoxaban; last dose
Aspirin and clopidogrel — associated with ED deterioration
Heparin or LMWH
Illicit substances
▶
Cocaine and sympathomimetics — acute hypertensive ICH risk
Amphetamines
Alcohol binge pattern — significant risk factor
Risk factors
Hypertension history
▶
Strongest modifiable risk factor
Medication adherence and BP control
Cerebral amyloid angiopathy risk
▶
Age over 65 years
Prior cognitive decline or dementia
Lobar ICH pattern association
Vascular lesion risk
▶
Known AVM, aneurysm, or cavernous malformation
Prior neurosurgical procedures
Additional risk factors
▶
Liver disease or uremia — coagulopathy association
Hematologic disorders — thrombocytopenia
Chronic kidney disease — drug dosing relevance
Family history
▶
Hemorrhagic stroke
Cerebral aneurysm or AVM
Coagulopathy or hypercoagulable state
Collateral history
Witness-reported events
▶
Exact time of symptom onset
Witnessed seizure
Fall or trauma preceding event
Prior cognitive decline
▶
Dementia — cerebral amyloid angiopathy marker
Baseline function for prognostic context
Social and living context
▶
Living situation affecting disposition planning
Substance use history from family or collateral
Physical Exam
Vital signs
Blood pressure
▶
90% present with SBP exceeding 160 mmHg
▶
Acute hypertension universal — do not assume primary hypertensive urgency
Cushing response — SBP rise with bradycardia
Respiratory assessment
▶
Rate and pattern
▶
Cheyne-Stokes respiration — bihemispheric or diencephalic
Central neurogenic hyperventilation — midbrain
SpO2 on room air
Temperature
▶
Central fever — dysautonomia pattern
Infection overlap exclusion
Heart rate
▶
Bradycardia with rising BP — Cushing triad
Tachycardia with pain or fever
Neurological examination
Level of consciousness
▶
Glasgow Coma Scale — GCS
▶
GCS below 13 — significantly predicts hemorrhagic vs ischemic stroke (OR 4.37)
GCS 3 to 4 — critical, very high mortality
NIHSS score
▶
Baseline NIHSS 10 or above — optimal for predicting poor 90-day outcomes
Pupillary exam
▶
Size and reactivity
▶
Unilateral dilation — transtentorial herniation
Bilateral fixed dilation — brainstem failure
Conjugate gaze deviation
▶
Gaze preference toward lesion — basal ganglia
Downward and inward gaze with miotic pupils — thalamic
Ocular bobbing — pontine hemorrhage
Motor examination
▶
Hemiplegia pattern — localizes hemorrhage
▶
Contralateral hemiplegia — supratentorial
Crossed deficit — brainstem
Bilateral Babinski signs
▶
Hemorrhage extending beyond single territory
Decorticate or decerebrate posturing
▶
Severe mass effect
Cerebellar examination
▶
Ataxia, dysmetria, truncal instability
▶
Cerebellar hemorrhage pattern
Inability to stand — cerebellar or posterior fossa mass effect
Language and cognition
▶
Aphasia — dominant hemisphere involvement
Neglect — nondominant parietal
Systemic examination
Cardiovascular
▶
Irregular rhythm — atrial fibrillation as risk factor
Cardiac murmurs — endocarditis differential
Signs of anticoagulant-related bleeding
▶
Bruising pattern
Petechiae — thrombocytopenia
Nuchal rigidity
▶
Intraventricular extension or subarachnoid component
Kernig and Brudzinski signs
PITFALLS
Clinical exam cannot reliably distinguish hemorrhagic from ischemic stroke
▶
Imaging is mandatory in all cases
Clinical scoring systems have insufficient accuracy for management decisions
Early prognostication unreliable
▶
Avoid premature withdrawal of care in first 24 to 48 hours
ICH score alone insufficient for limiting life-sustaining treatment
Differential Diagnosis
Immediate life threats
Ischemic stroke
▶
ICD-10 I63
▶
Cannot be distinguished clinically — imaging mandatory
NIHSS overlap significant
Subarachnoid hemorrhage
▶
ICD-10 I60
▶
Thunderclap headache, meningismus
May coexist with ICH
CT sensitivity 98% within 6 hours of onset
Hemorrhagic transformation of ischemic infarct
▶
ICD-10 I63 with hemorrhagic conversion
▶
Especially post-thrombolysis
Cardioembolic infarcts more prone
Structural intracranial lesions
Intracranial tumor with hemorrhage
▶
ICD-10 C71
▶
Melanoma, renal cell, choriocarcinoma — hemorrhage-prone metastases
MRI helps differentiate
Arteriovenous malformation rupture
▶
ICD-10 Q28.2
▶
Younger patients without hypertension
CTA or MRA reveals underlying lesion
Cerebral aneurysm rupture
▶
Perimesencephalic or intraparenchymal location
▶
Angiography required if high suspicion
Cerebral cavernous malformation
▶
ICD-10 Q28.3
▶
Characteristic popcorn lesion on MRI
Recurrent small bleeds
Vascular and thrombotic emergencies
Cerebral venous sinus thrombosis
▶
ICD-10 G08
▶
Young patients, pregnancy, hypercoagulable states
Venous infarction with hemorrhage pattern on MRI
Reversible cerebral vasoconstriction syndrome
▶
Thunderclap headache, recurrent
▶
Typically younger women, postpartum or medication related
Hypertensive encephalopathy
▶
PRES pattern on MRI
▶
Posterior predominant edema
Extreme BP elevation
Traumatic and other etiologies
Subdural hematoma
▶
ICD-10 S06.4
▶
Trauma history or anticoagulation
Crescent-shaped collection on CT
Epidural hematoma
▶
ICD-10 S06.4
▶
Biconvex shape, arterial bleeding
Temporal bone fracture with middle meningeal artery injury
Septic emboli with hemorrhagic conversion
▶
Endocarditis history
▶
Multiple lesions at grey-white junction
Laboratory Tests
Essential initial workup
Coagulation studies
▶
PT/INR
▶
INR 1.4 or above on VKA — triggers immediate reversal
Result influences reversal agent selection
aPTT
▶
Heparin effect detection
Intrinsic pathway coagulopathy
DOAC-specific assays when applicable
▶
Anti-Xa level — rivaroxaban and apixaban
Dilute thrombin time — dabigatran
Results guide PCC dosing if time allows
Complete blood count
▶
Platelet count
▶
Below 100 000 — transfusion threshold for surgical candidates
Anemia associated with hematoma expansion and poor outcomes
White cell count
▶
Leukocytosis — concurrent infection or stress response
Metabolic and organ function
Comprehensive metabolic panel
▶
Glucose
▶
Hyperglycemia worsens outcomes — target normoglycemia
Goal glucose 7.8 to 10 mmol/l
Creatinine and BUN
▶
Uremia — coagulation impact
Drug dosing adjustments
Hepatic panel
▶
Hepatic coagulopathy assessment
Synthetic function impact on reversal
Electrolytes
▶
Sodium — SIADH or cerebral salt wasting risk
▶
Hyponatremia worsens cerebral edema
Potassium — arrhythmia risk with QTc prolongation
Cardiac and perfusion markers
Troponin
▶
Elevated in 20 to 40% of ICH patients
▶
Associated with increased mortality
Neurogenic cardiac injury mechanism
Exclude primary ACS as etiology
ECG
▶
QTc prolongation — most common finding (19 to 67%)
▶
Associated with IVH and hematoma over 30 mL
ST depression (19 to 41%) — thalamic location, insular involvement
Cerebral T-waves — T-wave inversion pattern
Life-threatening ventricular arrhythmia risk — continuous monitoring warranted
Additional targeted labs
Toxicology screen
▶
Urine toxicology — cocaine, amphetamines
▶
Young patient without hypertension history
Guides etiology and recurrence risk counseling
Pregnancy test
▶
Women of childbearing age — mandatory
▶
Eclampsia, HELLP, cerebral venous thrombosis considerations
Type and screen
▶
Anticipation of surgical intervention or transfusion
Inflammatory markers
▶
ESR and CRP when vasculitis suspected
▶
Cerebral vasculitis rare but treatable cause
Diagnostic Tests
Scoring Systems
ICH Score
▶
Five-variable prognostic tool
▶
GCS (3 to 4 = 2 points; 5 to 12 = 1 point; 13 to 15 = 0 points)
ICH volume 30 mL or above = 1 point
IVH presence = 1 point
Infratentorial origin = 1 point
Age 80 or above = 1 point
Score 0 — 30-day mortality 0%
▶
Score 2 — 26% 30-day mortality
Score 4 — 97% 30-day mortality
Score 5 to 6 — near 100% 30-day mortality
Serial ICH Score at 6 hours improves prognostic accuracy
▶
AUC 0.914 at 6 hours vs 0.890 at admission
Recalculate after CT repeat
Limitation — ICH score alone insufficient for withdrawing life-sustaining treatment
NIHSS
▶
Neurological deficit quantification
▶
Baseline NIHSS 10 or above — optimal cutpoint for poor 90-day outcome prediction
INTERACT studies supported NIHSS prognostic value
Serial monitoring — trend more informative than single score
Spot Sign on CTA
▶
Contrast extravasation within hematoma on CTA
▶
Sensitivity 51%, specificity 85% for hematoma expansion
Presence escalates urgency of BP reduction and reversal
MRI
MRI brain indications
▶
Subacute or chronic hemorrhage evaluation
▶
Identifies hemosiderin deposits from prior bleeds
Gradient echo or SWI sequences most sensitive for microbleeds
Underlying lesion identification
▶
Tumor-associated hemorrhage — ring enhancement post-contrast
AVM or cavernous malformation — characteristic appearance
Cerebral amyloid angiopathy assessment
▶
Multiple lobar microbleeds on SWI
Boston criteria supported by MRI findings
MRI limitations in acute ICH
▶
Acute phase MRI comparable to CT for sensitivity
▶
Less available in emergency setting
Not first-line for acute diagnosis
Patient cooperation and monitoring constraints
▶
Agitated or unstable patients — CT preferred
MRI-incompatible devices require pre-scan check
Repeat MRI at follow-up
▶
3 months after discharge to detect underlying lesion
▶
Hematoma may have compressed an AVM acutely
Gadolinium contrast enhancement assessment
CT
Non-contrast CT head — first-line imaging
▶
Rapid and widely available
▶
Sensitivity and specificity near 100% for acute ICH
Recommended as immediate first-line by AHA/ASA 2022 — Class I
Key findings
▶
Hyperdense lesion in parenchyma
Volume estimated by ABC/2 formula
Intraventricular extension — associated with hydrocephalus
Midline shift quantification
Herniation patterns
CT angiography
▶
Spot sign detection — active extravasation predictor
▶
Guides urgency of BP reduction
Vascular lesion identification
▶
AVM, aneurysm, dural fistula
Indicated in young patients without hypertension — Class I recommendation
ACR Appropriateness Criteria — CTA appropriate for acute hemorrhagic stroke
Repeat CT protocols
▶
Repeat at 6 hours for hematoma expansion assessment
▶
Expansion defined as 33% or more volume increase or 6 mL absolute increase
Repeat if neurological deterioration at any time
24-hour CT before pharmacological DVT prophylaxis initiation
Ultrasound
Transcranial Doppler
▶
ICP estimation non-invasively
▶
Pulsatility index elevation correlates with elevated ICP
Operator dependent
Cerebral autoregulation assessment
▶
Research tool with emerging bedside application
Cardiac ultrasound
▶
Echocardiography — TTE or TEE
▶
Intracardiac thrombus or structural disease if cardioembolic source suspected
LV wall motion abnormality — neurogenic cardiac injury evaluation
Troponin elevation plus LV dysfunction — Takotsubo pattern in ICH
Neck vascular ultrasound
▶
Carotid duplex — atherosclerotic disease evaluation
▶
Not primary in acute ICH but relevant to risk stratification
Venous duplex for DVT screening
▶
DVT risk 4 times higher in ICH than ischemic stroke
Routine screening in immobilized patients
Disposition
Level of care
ICU or neurocritical care unit — all ICH patients
▶
Stroke unit care reduces death and dependency (OR 0.59)
▶
AHA/ASA Class I recommendation
Continuous BP and neurological monitoring required
▶
Hourly neuro checks minimum initially
Transfer to facility with neurocritical care and neurosurgical capability if unavailable locally
▶
Do not delay transfer for extended stabilization
Neurosurgical consultation triggers
▶
Cerebellar hemorrhage over 3 cm or over 15 mL
▶
Neurological deterioration, brainstem compression, or hydrocephalus
Immediate surgical evacuation plus or minus EVD
IVH with hydrocephalus — EVD placement
Supratentorial ICH over 20 to 30 mL with GCS 5 to 12
▶
Minimally invasive surgery candidate discussion
Clinical deterioration with mass effect at any volume
Goals of care
Avoid early DNR or withdrawal of care in first 24 to 48 hours
▶
Early prognostication unreliable — self-fulfilling prophecy risk
▶
AHA/ASA Class I recommendation
ICH score not sole basis for limiting life-sustaining treatment
Recovery after ICH often delayed vs ischemic stroke of similar severity
Family meeting within 24 hours
▶
Prognosis discussion with uncertainty framing
▶
Delayed recovery timeline counseling
Rehabilitation potential assessment when stabilized
Transfer criteria
Transfer to comprehensive stroke center
▶
Neurosurgical intervention required
▶
EVD, MIS, craniotomy
Neurocritical care monitoring not available locally
Minimize transfer time — time-sensitive for expansion window
Treatment
Airway and respiratory management
Intubation indications
▶
GCS 8 or below
▶
Rapid sequence intubation
Avoid prolonged laryngoscopy — ICP spike risk
Loss of airway protective reflexes
▶
Suction and positioning pre-intubation
Post-intubation targets
▶
SpO2 94 to 99%
▶
Avoid hypoxia and hyperoxia
PaCO2 35 to 45 mmHg
▶
Avoid hypocapnia except as temporary herniation bridge
Brief hyperventilation for impending herniation
▶
Target PaCO2 30 to 35 mmHg as bridge only
Definitive treatment with hyperosmolar therapy or surgery required
Blood pressure management
Target SBP 140 mmHg for mild to moderate ICH
▶
Presentation SBP 150 to 220 mmHg
▶
Achieve target within 1 hour — AHA/ASA Class IIa recommendation
Smooth sustained control preferred
Avoid SBP below 130 mmHg
▶
Harmful — associated with perihematomal ischemia
Nicardipine IV infusion
▶
Initial 5 mg/h
▶
Titrate 2.5 mg/h every 5 to 15 minutes
Maximum 15 mg/h
Smooth predictable dose-response
▶
Preferred by AHA/ASA guidelines
Labetalol IV
▶
10 to 20 mg IV bolus over 2 minutes
▶
Repeat every 10 minutes as needed
Maximum cumulative 300 mg
Infusion 2 mg/min if needed
▶
Titrate to SBP target
Avoid in reactive airways disease or acute decompensated heart failure
Anticoagulation reversal
Warfarin reversal — INR 1.4 or above
▶
4-factor PCC — Kcentra
▶
25 to 50 units/kg IV based on INR and weight
Maximum 5000 units
Normalizes INR within minutes
Vitamin K IV
▶
10 mg slow IV infusion
Prevents INR rebound over hours
Repeat INR 30 minutes post-PCC — re-dose if INR above 1.4
Dabigatran reversal
▶
Idarucizumab 5 g IV
▶
2.5 g IV over 5 to 10 minutes, repeat second dose
Complete reversal within minutes
Class I recommendation
If idarucizumab unavailable
▶
aPCC 50 to 80 units/kg IV
Dialysis removes dabigatran — consider in renal failure
Factor Xa inhibitor reversal
▶
4-factor PCC
▶
25 to 50 units/kg IV
Best available option in U.S. after andexanet alfa withdrawal
aPCC 50 to 80 units/kg IV as alternative
Timing and last dose critical — within 12 to 24 hours of last dose most effective
Heparin reversal
▶
Protamine sulfate
▶
1 mg per 100 units heparin administered in preceding 2 to 3 hours
Maximum 50 mg slow IV
LMWH — partial reversal with protamine
▶
1 mg protamine per 1 mg enoxaparin; max 50 mg
Intracranial pressure management
Hyperosmolar therapy
▶
Mannitol 20%
▶
0.25 to 1 g/kg IV bolus
Repeat every 4 to 6 hours as needed
Target serum osmolality below 320 mOsm/kg
Hypertonic saline
▶
3% NaCl 250 mL IV over 30 minutes
23.4% NaCl 30 mL IV for herniation emergency
Target serum sodium 145 to 155 mmol/l in severe ICP
Hypertonic saline may be preferred over mannitol in hypovolemic patients
Head of bed elevation
▶
30 degrees — reduces ICP without compromising CPP
▶
Avoid head turns and neck compression
Sedation for elevated ICP
▶
Propofol infusion
▶
5 to 50 mcg/kg/min IV
Reduces CMRO2 and ICP
Fentanyl for analgesia
▶
25 to 100 mcg IV PRN for painful stimuli
Blunts ICP spikes during care
Seizure management
No prophylactic antiseizure medications
▶
Not recommended — AHA/ASA Class III recommendation
Treat only clinical or electrographic seizures
Continuous EEG monitoring
▶
Recommended for depressed consciousness — AHA/ASA
▶
Subclinical seizures in 30% of patients with depressed GCS
EEG monitoring duration individualized
Acute seizure treatment
▶
Lorazepam 0.1 mg/kg IV for active seizure
▶
Maximum 4 mg per dose
Repeat once if no response within 5 minutes
Levetiracetam for maintenance if seizure occurred
▶
1000 to 1500 mg IV twice daily
Preferred — no significant drug interactions
Supportive care bundle
Glucose control
▶
Target 7.8 to 10 mmol/l
▶
Hypoglycemia equally harmful — avoid
Insulin infusion if persistently above 10 mmol/l
Temperature control — normothermia
▶
Paracetamol 1 g IV every 6 hours for fever
▶
Avoid NSAIDs — platelet effect
Active cooling for refractory hyperthermia
▶
Target temperature 36 to 37.5 degrees Celsius
DVT prophylaxis
▶
Intermittent pneumatic compression — start day of diagnosis
▶
Graduated compression stockings alone not effective
Pharmacological prophylaxis — start 48 to 96 hours after onset
▶
Once CT documents hemorrhage stability
LMWH or UFH subcutaneous
Class IIb recommendation
Early dysphagia screening before oral intake
▶
Speech language pathology referral
▶
Aspiration pneumonia prevention
NPO until screened
Mobility
▶
Avoid aggressive mobilization within first 24 hours
▶
Associated with worsened 14-day mortality
Rehabilitation activities may begin 24 to 48 hours after moderate ICH
▶
Stretching and functional task training
Surgical interventions
Cerebellar hemorrhage
▶
Surgical evacuation plus or minus EVD
▶
Hematoma over 3 cm or over 15 mL with deterioration
Brainstem compression or hydrocephalus
Class I AHA/ASA recommendation
Supratentorial ICH
▶
Minimally invasive surgery — MIS
▶
Volume over 20 to 30 mL with GCS 5 to 12
Reduces mortality; functional outcome benefit uncertain
Class IIb AHA/ASA recommendation
Conventional craniotomy
▶
Not clearly beneficial for most supratentorial ICH
Consider for accessible superficial hematomas with mass effect
External ventricular drain
▶
IVH with obstructive hydrocephalus
May combine with thrombolytic irrigation
Special Populations
Pregnancy
Etiologic considerations
▶
Eclampsia and severe preeclampsia
▶
BP over 160/110 mmHg in pregnancy is hypertensive emergency
HELLP syndrome — hemolysis, elevated liver enzymes, low platelets
Cerebral venous sinus thrombosis
▶
Third trimester and postpartum peak risk
Paradoxical hemorrhagic infarction
Pre-existing AVM — rupture risk increased in pregnancy
▶
Hemodynamic and hormonal changes
Blood pressure targets in pregnancy
▶
Target SBP 140 to 150 mmHg — avoid aggressive lowering
▶
Uteroplacental perfusion dependent on BP
Labetalol IV first-line
▶
20 mg IV, then 40 to 80 mg every 10 minutes
Maximum 220 mg cumulative
Hydralazine IV alternative
▶
5 to 10 mg IV every 20 minutes
Avoid nicardipine in early pregnancy — limited safety data
Eclampsia management
▶
Magnesium sulfate for seizure prophylaxis and treatment
▶
4 to 6 g IV loading dose over 15 to 20 minutes
1 to 2 g/h maintenance infusion
Delivery planning — obstetrics consultation mandatory
▶
Definitive treatment for eclampsia
Imaging in pregnancy
▶
Non-contrast CT head with abdominal shielding — acceptable in emergency
▶
Fetal radiation dose negligible with head CT
MRI preferred over CT angiography to limit contrast and radiation
Gadolinium — limited use, only if essential
Anticoagulant reversal
▶
LMWH preferred over warfarin in pregnancy — if reversal needed
Protamine for LMWH reversal
Warfarin crosses placenta — avoid in pregnancy; if used, PCC plus vitamin K
Geriatric
Cerebral amyloid angiopathy
▶
Major cause of lobar ICH in elderly
▶
Boston criteria modified for clinical diagnosis
Microbleed burden on SWI guides anticoagulation decisions
High recurrence risk
▶
Annual recurrence rate 2 to 3% vs 0.5 to 1% for deep ICH
Anticoagulation resumption decisions individualized
Physiological considerations
▶
Reduced cerebral reserve
▶
Worse outcomes at equivalent hematoma volume
Cognitive baseline critical for prognosis
Polypharmacy
▶
Multiple agents increasing hemorrhage risk
Drug interactions affecting reversal
Renal function — drug dosing adjustment
▶
PCC dosing typically weight-based without renal adjustment
Levetiracetam dose reduction in reduced GFR
Goals of care in elderly
▶
Early family meeting — advance directives
▶
Premature prognostication still harmful — 48-hour rule applies
Frailty as independent outcome predictor
▶
Clinical Frailty Scale useful adjunct to ICH score
Rehabilitation potential even in elderly — do not exclude from rehab
Anticoagulation resumption
▶
High-risk decision requiring neurology and cardiology input
▶
Atrial fibrillation — balance stroke prevention vs recurrent ICH
Typically deferred 4 to 8 weeks minimum after deep ICH
Lobar ICH with amyloid — often contraindication to resumption
Pediatrics
Etiology differences from adults
▶
AVM — most common cause in children
▶
Annual hemorrhage risk 2 to 4% per year
CTA or MRA mandatory in pediatric ICH
Coagulopathy — hemophilia, von Willebrand disease, thrombocytopenia
▶
Hematology consultation early
Cerebral venous sinus thrombosis
▶
Neonates and adolescents particularly
MRV to confirm
Hypertension in children
▶
Renal disease most common secondary cause
Pediatric BP targets
▶
Age-specific normal ranges apply
▶
Neonates SBP 60 to 90 mmHg normal range
Adolescents approaching adult targets
Nicardipine IV weight-based
▶
0.5 to 3 mcg/kg/min infusion
Titrate to age-appropriate target
Weight-based dosing considerations
▶
Mannitol 0.25 to 0.5 g/kg IV bolus for ICP
▶
Repeat every 4 to 6 hours
Levetiracetam for seizure
▶
20 to 60 mg/kg/day divided every 12 hours
Maximum 3000 mg/day
Lorazepam 0.05 to 0.1 mg/kg IV for acute seizure
▶
Maximum 4 mg per dose
Neurosurgical approach
▶
Lower threshold for surgical exploration in children
▶
Vascular lesions require definitive treatment
Brain plasticity supports more aggressive intervention
Background
Epidemiology
Incidence and burden
▶
ICH accounts for 10 to 15% of all strokes
▶
Annual U.S. incidence approximately 80 000 cases
Global burden higher in lower-income countries
30-day mortality 30 to 40%
▶
Most deaths occur within first 48 hours
Majority of survivors have significant disability
Hematoma expansion occurs in approximately 33% within first hours
▶
Major driver of early neurological deterioration and mortality
Demographic distribution
▶
Incidence increases sharply with age
Risk approximately 2 times higher in Asian populations vs White
▶
1.6 times higher in Black and Hispanic persons vs White in U.S.
Hypertension accounts for majority of deep ICH
▶
Basal ganglia, thalamus, cerebellum, brainstem locations
Cerebral amyloid angiopathy accounts for majority of lobar ICH in elderly
Cardiac complications
▶
Cardiac complications occur in approximately 13% of ICH patients
▶
Stroke-heart syndrome mechanism
Elevated troponin in 20 to 40% — associated with increased mortality
Pathophysiology
Hemorrhage initiation and expansion
▶
Hypertensive small vessel disease
▶
Lipohyalinosis and microaneurysm formation in deep perforators
Basal ganglia and thalamic locations predominate
Cerebral amyloid angiopathy
▶
Amyloid deposition in cortical and leptomeningeal vessels
Lobar hemorrhages, microbleeds, superficial siderosis
Hematoma expansion
▶
Initial hemorrhage disrupts surrounding vessels
Mechanical dissection and coagulopathy perpetuate bleeding
Perihematomal edema develops in hours to days
Secondary injury mechanisms
▶
Mass effect and herniation
▶
Midline shift correlates with volume and location
Transtentorial herniation — descending and central
Intraventricular extension
▶
Obstructive hydrocephalus
Periventricular edema propagation
Perihematomal edema
▶
Peaks days 3 to 7 after onset
Thrombin and iron toxicity mechanism
Neurogenic cardiac injury
▶
Hypothalamic and insular activation causes catecholamine surge
Subendocardial ischemia, arrhythmias, LV dysfunction
Classification by location
▶
Deep hemorrhages — basal ganglia, thalamus, cerebellum, brainstem
▶
Hypertension primary etiology
Lobar hemorrhages — cortical or subcortical
▶
CAA in elderly; AVM or tumor in younger patients
Infratentorial — cerebellar or brainstem
▶
High mortality when brainstem involved
Therapeutic Considerations
Bundle-of-care approach — INTERACT3
▶
Simultaneous intensive BP control plus glucose normalization plus antipyrexia plus reversal
▶
Implemented within 6 hours of onset
Improved functional outcomes at 6 months — landmark trial
Treating single elements in isolation less effective
Anticoagulation reversal principles
▶
Speed of reversal critical — each minute of continued expansion increases mortality
▶
Do not wait for complete lab results before initiating reversal
PCC preferred over FFP for VKA reversal
▶
Faster INR normalization
Lower volume overload risk
Andexanet alfa withdrawn from U.S. market — no longer available
Surgical intervention evidence
▶
MISTIE III trial — MIS surgery reduces mortality but functional benefit modest
▶
Ongoing trials refining patient selection
Cerebellar evacuation — Class I evidence for deteriorating patients
Conventional craniotomy for supratentorial ICH — not clearly beneficial
▶
Cochrane review 2025 — uncertain functional benefit
Antithrombotic resumption after ICH
▶
Complex risk-benefit individualization
▶
Deep ICH vs lobar ICH — different risk profiles
Atrial fibrillation with high embolic risk — most challenging scenario
Typically defer decision 4 to 8 weeks minimum
▶
MRI to exclude CAA before resuming
Cochrane review 2023 — insufficient evidence for definitive recommendation
Secondary prevention
▶
Sustained BP control — cornerstone of recurrence prevention
▶
Target SBP below 130 mmHg long-term — AHA/ACC guideline
Alcohol cessation, cocaine avoidance, smoking cessation
Statin use — unclear ICH risk; individualized in context of cardiovascular risk
Patient Discharge Instructions
copy discharge instructions
Copy
Intracerebral hemorrhage home care
▶
Blood pressure medications — take exactly as prescribed every day
▶
Do not skip doses — uncontrolled BP is the main cause of recurrence
No lifting, straining, or strenuous activity until cleared by neurology
No driving until cleared by physician — seizure and neurological risk
Alcohol in any amount may raise your blood pressure or cause falls — avoid
No cocaine, amphetamines, or stimulant drugs
All blood thinners and aspirin stopped unless neurology advises restart
Warning signs — return to emergency immediately
▶
New or worsening headache
New weakness, numbness, or drooping on one side of face or body
Trouble speaking or understanding speech
Vision changes in one or both eyes
Sudden loss of balance or inability to walk
Seizure — any shaking episode or loss of consciousness
Confusion, unusual sleepiness, or difficult to wake
Nausea and vomiting with any of the above
Swelling, redness, or pain in legs — blood clot sign
Sudden shortness of breath or chest pain
Follow up instructions
▶
Neurology or neurosurgery appointment within 2 to 4 weeks
Repeat brain MRI at approximately 3 months to check for underlying cause
Blood pressure check with your family doctor within 1 week
Speech therapy, physiotherapy, and occupational therapy referrals as recommended
Do not resume any blood thinners without neurology approval
Lifestyle guidance
▶
Low-salt diet to help control blood pressure
High fruit and vegetable intake — long-term BP benefit
Do not drink alcohol in binge amounts
Take medications at the same time each day
Recovery after brain hemorrhage is often slower than other strokes — progress may continue for months
References
Guidelines and key sources
Primary guidelines
▶
AHA/ASA 2022 Guideline for Management of Spontaneous Intracerebral Hemorrhage — Greenberg SM et al., Stroke 2022
▶
Comprehensive evidence-based management framework
Class I and IIa/IIb recommendations cited throughout
2024 AHA/ASA Performance and Quality Measures for ICH — Ruff IM et al., Stroke 2024
ACR Appropriateness Criteria Cerebrovascular Diseases — Pannell JS et al., JACR 2024
Landmark trials and systematic reviews
▶
INTERACT3 trial — bundle-of-care approach, Anderson CS et al.
▶
Simultaneous targets improved outcomes
PATCH trial — platelet transfusion harm in antiplatelet-associated ICH
MISTIE III — minimally invasive surgery for ICH, mortality benefit
Cochrane review — surgery for supratentorial ICH, Wilting FN et al. 2025
Cochrane review — antithrombotic treatment after ICH, Cochrane A et al. 2023
Key literature
▶
Sheth KN. Spontaneous Intracerebral Hemorrhage. NEJM 2022
▶
Comprehensive clinical review
Cordonnier C, Demchuk A, Ziai W, Anderson CS. Intracerebral Haemorrhage: Current Approaches to Acute Management. Lancet 2018
Mayer SA, Rincon F. Treatment of Intracerebral Haemorrhage. Lancet Neurology 2005
Morotti A et al. Intracerebral Haemorrhage Expansion. Lancet Neurology 2023
ICH Score — Hemphill JC et al., Stroke 2001
▶
Validated five-variable prognostic score
Coding references
▶
ICD-10 I61 — intracerebral hemorrhage
▶
I61.0 — subcortical hemispheric
I61.1 — cortical hemispheric
I61.3 — cerebellar
I61.4 — intraventricular
I61.9 — unspecified
SNOMED CT — spontaneous intracerebral hemorrhage disorder
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.
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Management Protocols
Intracerebral Hemorrhage