Intracerebral Hemorrhage
Spontaneous bleeding into brain parenchyma. Hypertension is #1 cause. Rapid BP lowering to SBP < 140. Reverse anticoagulation STAT. Hematoma expansion in first 6h drives mortality. Neurosurgery consult for all ICH.
🔍 Overview
Etiology by Location
| Location | Most Likely Cause |
|---|---|
| Basal ganglia / putamen | Hypertension (#1 cause, #1 location) |
| Thalamus | Hypertension |
| Pons | Hypertension |
| Cerebellum | Hypertension (surgical emergency if > 3 cm) |
| Lobar (cortical) | Cerebral amyloid angiopathy (elderly), AVM (young), tumor |
Hematoma expansion occurs in ~30% of ICH patients within the first 6 hours. This is the main driver of early deterioration. Aggressive BP control and anticoagulation reversal are TIME-CRITICAL.
ICH Score (Hemphill, 2001)
| Component | Criteria | Points |
|---|---|---|
| GCS 3–4 | Comatose | 2 |
| GCS 5–12 | Obtunded / moderate impairment | 1 |
| GCS 13–15 | Alert / mild impairment | 0 |
| ICH volume ≥ 30 mL | Use ABC/2 formula on CT | 1 |
| ICH volume < 30 mL | 0 | |
| IVH present | Intraventricular extension of hemorrhage | 1 |
| Infratentorial origin | Cerebellum or brainstem | 1 |
| Age ≥ 80 | 1 |
ICH Score → 30-day mortality: 0 = 0%, 1 = 13%, 2 = 26%, 3 = 72%, 4 = 97%, 5 = 100%. Caution: Do NOT use as sole basis for withdrawal of care, prognostic nihilism contributes to self-fulfilling prophecies. Early aggressive care is warranted for all patients.
ICH Volume Estimation, ABC/2 Method
On CT, measure: A = largest diameter of hemorrhage (cm), B = diameter perpendicular to A on same slice (cm), C = number of CT slices with hemorrhage × slice thickness (cm). Volume ≈ (A × B × C) / 2 mL.
🚨 Management
Acute Management
- BP control: Target SBP < 140 within 1 hour (INTERACT2, 2013). Use Nicardipine (Cardene) or Clevidipine (Cleviprex) drip.
- Reverse anticoagulation STAT:
- Warfarin → 4-factor PCC (KCentra) + Vitamin K 10 mg IV
- Dabigatran → Idarucizumab (Praxbind) 5g IV
- Rivaroxaban/Apixaban → Andexanet Alfa (Andexxa) or 4F-PCC
- Neurosurgery consult -all ICH. Cerebellar ICH > 3 cm or with hydrocephalus → surgical evacuation
- ICP management: HOB 30°, osmotic therapy (mannitol or hypertonic saline), EVD if hydrocephalus
- Seizure prophylaxis: NOT routine -treat only clinical seizures. Continuous EEG if altered.
- Tranexamic acid (TXA): Consider within 3 hours of injury, especially in mild-to-moderate TBI. CRASH-3, 2019 showed reduced head-injury related death when given early.
BP Management, Key Trials
| Trial | Target | Key Finding |
|---|---|---|
| INTERACT2, 2013 | SBP < 140 mmHg within 1h | Improved functional outcomes (mRS). Safe. Current standard of care. |
| ATACH-2, 2016 | SBP 110–139 vs 140–179 | No additional benefit from more aggressive lowering. Increased renal AKI. |
Bottom line: Target SBP < 140 within 1 hour (INTERACT2). Do NOT push below 110–120 (ATACH-2 showed harm). Use nicardipine or clevidipine drip with arterial line monitoring.
Anticoagulant Reversal, Emergency Protocol
| Anticoagulant | Reversal Agent | Dose | Key Notes |
|---|---|---|---|
| Warfarin | 4-factor PCC (KCentra) + Vitamin K | PCC 25–50 units/kg IV + Vit K 10 mg IV | PCC reverses in minutes. Vit K sustains reversal (takes 6–24h). Do NOT use FFP alone (slow, volume overload). |
| Dabigatran (Pradaxa) | Idarucizumab (Praxbind) | 5 g IV (two 2.5g vials) | Monoclonal antibody fragment. Immediate, complete reversal. RE-VERSE AD, 2017 |
| Rivaroxaban / Apixaban (Xa inhibitors) | Andexanet alfa (Andexxa) | Low dose: 400mg bolus + 4mg/min x 2h; High dose: 800mg bolus + 8mg/min x 2h | Recombinant Xa decoy. ANNEXA-4, 2019. If unavailable, use 4F-PCC 50 units/kg. |
| Heparin (UFH) | Protamine sulfate | 1 mg per 100 units heparin (last 2–3h of infusion) | Max 50 mg. Only partially reverses LMWH (~60%). |
Do NOT wait for coagulation studies. If patient is on anticoagulation and has ICH on CT, reverse EMPIRICALLY and immediately. Time to reversal correlates with hematoma expansion and mortality.
Surgical Indications
- Cerebellar ICH > 3 cm or with brainstem compression → Surgical evacuation (life-saving, often good outcomes)
- Obstructive hydrocephalus → EVD (external ventricular drain) placement, regardless of ICH location
- Supratentorial ICH with deterioration: Consider surgery for lobar hemorrhages within 1 cm of cortical surface. STICH II, 2013 showed no broad benefit for early surgery, but consider in deteriorating patients.
- Minimally invasive surgery: MISTIE III, 2019, catheter-based clot evacuation showed trend toward benefit if residual clot < 15 mL.
ICP Management
- Head of bed 30°, promotes venous drainage, reduces ICP
- Osmotic therapy: Mannitol 0.5–1 g/kg IV bolus OR hypertonic saline (23.4% 30 mL via central line, or 3% NaCl 250 mL bolus peripherally)
- EVD, both diagnostic (measure ICP) and therapeutic (drain CSF). Target ICP < 20 mmHg, CPP > 60 mmHg
- Avoid: hyperthermia (active cooling to normothermia), hyperglycemia (target glucose 140–180), hyponatremia
- Herniation protocol: If acute pupil dilation or posturing → hyperventilate briefly (target pCO2 30–35), give osmotic bolus, emergent CT and neurosurgery
Seizure Prophylaxis, The Debate
AHA/ASA Guidelines: Routine seizure prophylaxis is NOT recommended. Clinical seizures occur in 8–16% of ICH patients. Subclinical seizures (on EEG) occur in up to 30%. Levetiracetam is preferred if prophylaxis is used; phenytoin is associated with worse outcomes in ICH (Naidech, 2009). Continuous EEG monitoring recommended for patients with GCS decline out of proportion to hemorrhage size.
🧪 Workup
- Non-contrast CT head -STAT. Shows hyperdense (white) acute blood. First-line.
- CTA head -spot sign (contrast extravasation = active bleeding, predicts expansion)
- CBC, PT/INR, PTT, fibrinogen -coagulation status
- BMP, glucose
- Type and screen
- MRI -can evaluate underlying cause (tumor, AVM, cavernoma) once stable
- CTA/MRA -evaluate for vascular malformation if non-hypertensive location
💊 Medications
| Drug | Dose | Purpose |
|---|---|---|
| Nicardipine (Cardene) | 5–15 mg/h IV drip | BP control -titratable, no ICP effects |
| Clevidipine (Cleviprex) | 1–21 mg/h IV drip | Ultra-short acting alternative |
| 4-factor PCC (KCentra) | 25–50 units/kg IV | Warfarin reversal. Faster than FFP. |
| Idarucizumab (Praxbind) | 5 g IV | Dabigatran reversal. Immediate effect. |
| Mannitol (Osmitrol) | 0.5–1 g/kg IV bolus | ICP reduction -osmotic diuresis |
| Hypertonic Saline (23.4%) | 30 mL IV via central line | ICP crisis -can use via peripheral at lower concentration (3%) |
📋 On Rounds
Pimp Questions
What is the ICH Score and what does it predict?
Prognostic score for 30-day mortality: GCS 3-4 (+2), GCS 5-12 (+1), ICH volume ≥ 30 mL (+1), IVH present (+1), Infratentorial (+1), Age ≥ 80 (+1). Score 0 = 0% mortality, Score 5 = 100% mortality. Do NOT use as sole basis for withdrawal of care -prognostic models are imperfect and self-fulfilling prophecies contribute to poor outcomes.
Why is cerebellar hemorrhage a neurosurgical emergency?
The posterior fossa is a tight space. Cerebellar hemorrhage > 3 cm can cause: (1) Brainstem compression → rapid decline, (2) 4th ventricle obstruction → obstructive hydrocephalus, (3) Tonsillar herniation → death. Surgical evacuation is life-saving. EVD for hydrocephalus. These patients can have excellent outcomes with timely intervention -unlike supratentorial ICH.
How do you reverse DOACs in acute ICH?
Dabigatran: Idarucizumab (Praxbind) 5g IV -monoclonal antibody fragment, immediate full reversal. Rivaroxaban/Apixaban (factor Xa inhibitors): Andexanet alfa (Andexxa) -recombinant modified factor Xa decoy. If unavailable, use 4-factor PCC 50 units/kg IV. Key: Do NOT wait for drug levels. Time is brain -reverse empirically if recent DOAC use and ICH confirmed on CT.
What is the BP target in acute ICH and what trials support it?
Target SBP < 140 mmHg within 1 hour, supported by INTERACT2 (2013), which showed improved functional outcomes with intensive lowering. ATACH-2 (2016) tested even more aggressive targets (SBP 110–139) but showed no additional benefit and increased renal injury. Bottom line: aim for SBP < 140, but do not push below 110–120. Use nicardipine or clevidipine drip with an arterial line.
What is the "spot sign" on CTA and why does it matter?
The spot sign is a focus of contrast extravasation within the hematoma seen on CTA. It indicates active, ongoing bleeding and strongly predicts hematoma expansion (positive predictive value ~60–70%). Patients with a spot sign are at higher risk for clinical deterioration and may warrant more aggressive BP management and closer monitoring with repeat imaging.
Why is phenytoin avoided in ICH, and what is the preferred antiepileptic?
Phenytoin use in ICH is associated with worse functional outcomes, more fever, and longer ICU stays (Naidech, 2009). Levetiracetam (Keppra) is preferred if seizure prophylaxis or treatment is needed, it has a better side-effect profile, no drug-drug interactions, and does not require monitoring of drug levels.
How do you calculate ICH volume and why does it matter?
Use the ABC/2 method: A = largest hemorrhage diameter (cm), B = perpendicular diameter on same slice (cm), C = number of slices with hemorrhage x slice thickness (cm). Volume = (A x B x C) / 2 mL. Volume matters because: (1) ICH volume ≥ 30 mL is a component of the ICH Score predicting mortality, (2) volume > 60 mL in supratentorial ICH has ~90% mortality, (3) serial volume assessment detects hematoma expansion (≥33% or ≥6 mL increase).
When would you choose mannitol vs hypertonic saline for ICP management in ICH?
Both are osmotic agents that reduce ICP. Mannitol (0.5–1 g/kg IV): causes osmotic diuresis, avoid in hypotension as it depletes volume. Requires a Foley catheter. Monitor serum osmolality (hold if > 320). Hypertonic saline (HTS): 23.4% (30 mL) via central line or 3% NaCl (250 mL bolus) peripherally, preferred in hypotensive patients as it expands intravascular volume. Target Na 145–155. HTS may be more effective for refractory ICP elevation.
Clinical Examples
📋 Case 1, Hypertensive ICH with BP Management
Patient: 62-year-old male with HTN (non-adherent to meds), presents with sudden severe headache, left hemiparesis, and slurred speech. BP 218/112 on arrival. GCS 12.
CT Head: 25 mL right basal ganglia hemorrhage, no IVH, no hydrocephalus.
Management:
- Start nicardipine drip 5 mg/h, titrate to SBP < 140 within 1 hour (INTERACT2 target)
- Place arterial line for continuous BP monitoring
- Confirm no anticoagulant use → no reversal needed
- Neurosurgery consult, supratentorial, non-surgical candidate at this size
- Neuro checks q1h, repeat CT at 6 hours
- ICH Score = 1 (GCS 12 = +1) → 13% predicted 30-day mortality
Teaching point: Hypertensive basal ganglia hemorrhage is the classic ICH. Rapid BP control to SBP < 140 is the cornerstone of management. Do NOT overshoot below 110 (ATACH-2).
📋 Case 2, Warfarin-Associated ICH with Reversal
Patient: 78-year-old female on warfarin (INR 3.8) for atrial fibrillation. Found by family with confusion and right-sided weakness. BP 176/94. GCS 10.
CT Head: 40 mL left frontoparietal lobar hemorrhage with intraventricular extension.
Management:
- 4-factor PCC (KCentra) 25–50 units/kg IV STAT, do NOT wait for pharmacy to mix FFP
- Vitamin K 10 mg IV, sustains reversal after PCC wears off
- Nicardipine drip → target SBP < 140
- ICH Score = 4 (GCS 10 = +1, volume ≥ 30 = +1, IVH = +1, age ≥ 80 = +1) → 97% predicted mortality
- Repeat INR 30 min after PCC, goal < 1.5
- Goals of care discussion with family, but do NOT withdraw care based solely on ICH score
Teaching point: Warfarin-associated ICH has the worst outcomes. Time to INR reversal directly impacts hematoma expansion. PCC reverses in minutes vs hours for FFP. Always give vitamin K concurrently for sustained reversal.
📋 Case 3, Cerebellar Hemorrhage Needing Surgery
Patient: 55-year-old male with HTN, presents with sudden occipital headache, vomiting, severe ataxia, unable to stand. BP 198/108. GCS 13 initially, drops to 9 over 30 minutes.
CT Head: 3.5 cm cerebellar hemorrhage with compression of 4th ventricle and early obstructive hydrocephalus.
Management:
- EMERGENT neurosurgery consult, this is a surgical emergency
- Suboccipital craniectomy and clot evacuation, life-saving for cerebellar ICH > 3 cm with mass effect
- EVD placement for obstructive hydrocephalus (caution: draining supratentorial CSF alone can worsen upward herniation)
- Nicardipine drip → SBP < 140
- HOB 30°, osmotic therapy as bridge to OR
- These patients can have excellent functional recovery with timely surgery, unlike supratentorial ICH
Teaching point: Cerebellar ICH is the one ICH where surgery is clearly beneficial. The posterior fossa is a confined space, a 3 cm hemorrhage can cause brainstem compression, obstructive hydrocephalus, and tonsillar herniation within hours. Rapid clinical deterioration (as in this case) demands emergent intervention.
⚡ Summary
The First 6 Hours Decide the Outcome
Hematoma expansion occurs in about 30% of patients within the first 6 hours and is the main driver of early deterioration. Blood pressure control and anticoagulation reversal are time-critical, which means they happen in the scanner corridor, not after admission.
Location Predicts the Cause
Basal ganglia and putamen (the commonest site), thalamus, pons and cerebellum → hypertension. Lobar → cerebral amyloid angiopathy in the elderly, or an underlying lesion. A young patient, an unusual location, or an atypical appearance means look for an AVM, aneurysm, tumor or venous sinus thrombosis with CTA or MRI, rather than assuming hypertension.
Blood Pressure: Low Enough, Not Too Low
Target systolic below 140 within the first hour (INTERACT2). Do not push below 110 to 120: ATACH-2 showed harm from over-aggressive lowering, largely renal. Use a titratable infusion, nicardipine or clevidipine, with an arterial line, since bolus dosing produces the swings that cause the harm.
Reverse Anticoagulation Empirically
If the patient is anticoagulated and has blood on CT, reverse immediately without waiting for coagulation studies. Time to reversal correlates with hematoma expansion and mortality. Warfarin → 4-factor PCC plus vitamin K (PCC over plasma: faster, smaller volume). Dabigatran → idarucizumab. Factor Xa inhibitors → andexanet alfa or PCC. Heparin → protamine.
Score It, But Do Not Let It Decide Care
ICH score maps to 30-day mortality: 0 = 0%, 1 = 13%, 2 = 26%, 3 = 72%, 4 = 97%, 5 = 100%. Do not use it as the sole basis for withdrawing care: prognostic nihilism is self-fulfilling, and early aggressive management improves outcomes in patients whose scores predicted otherwise. Estimate volume with ABC/2 at the bedside.
Know the Surgical Indications
Cerebellar hemorrhage above 3 cm, or with brainstem compression or hydrocephalus, needs urgent evacuation, and this is the one clear-cut surgical indication. An external ventricular drain for hydrocephalus or intraventricular extension. Supratentorial evacuation is not routinely beneficial and is reserved for deteriorating patients or superficial lobar clots. Decompressive craniectomy for refractory intracranial hypertension.
Manage ICP Without Making It Worse
Head of bed at 30 degrees, neck midline, treat pain, fever and agitation, and avoid hypotonic fluids. Hypertonic saline or mannitol for surges, with a target cerebral perfusion pressure of 60 to 70. Avoid prophylactic hyperventilation: it works for minutes by vasoconstriction and then worsens ischemia, so it is a bridge to definitive treatment only.
Do Not Give Prophylactic Antiepileptics
AHA/ASA does not recommend routine seizure prophylaxis. Clinical seizures occur in 8 to 16%, and subclinical seizures on EEG in up to 30%, so treat seizures that happen and get an EEG for unexplained depressed consciousness. If prophylaxis is used, levetiracetam is preferred; phenytoin is associated with worse outcomes. Also: hold anticoagulation, give mechanical VTE prophylaxis from day 1 and start pharmacologic prophylaxis at 48 to 96 h once the hematoma is stable, keep glucose and temperature controlled, and screen swallowing before anything goes by mouth.
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