Intracranial Hemorrhage

Intracranial hemorrhage includes intraparenchymal/intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), intraventricular hemorrhage, subdural hemorrhage, and epidural hemorrhage. Immediate management is driven less by the label than by airway protection needs, neurologic trajectory, hemorrhage location and size, hydrocephalus, mass effect, coagulopathy, and whether a surgically remediable lesion is likely. Hemorrhagic stroke has high early mortality; deterioration is commonly mediated by hematoma expansion, intraventricular extension, perihematomal edema, hydrocephalus, and raised intracranial pressure. PubMed+1PubMedHemorrhagic Stroke Overview - StatPearls - NCBI BookshelfPubMed2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association - PubMed

Perform focused ABC assessment, serial Glasgow Coma Scale and pupillary examinations, medication reconciliation for anticoagulants and antiplatelet agents, and immediate blood pressure measurement. Obtain CBC with platelets, PT/INR, aPTT, fibrinogen, renal and hepatic function, type and screen, and—where available—drug-specific testing such as anti-factor Xa activity for apixaban/rivaroxaban or thrombin time for dabigatran. A normal initial hemoglobin does not exclude important acute bleeding. PubMed+1PubMedMajor Bleeding in the Emergency Department - PMC - NIHPubMedHemorrhagic Stroke Overview - StatPearls - NCBI Bookshelf

Noncontrast CT is the first-line study for suspected acute ICH because it rapidly identifies hemorrhage, mass effect, ventricular extension, and hydrocephalus. Hematoma volume can be estimated using the ABC/2 method; larger volume, infratentorial location, intraventricular extension, and depressed consciousness are major prognostic variables. PubMed+1PubMedHemorrhagic Stroke Overview - StatPearls - NCBI BookshelfPubMed2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association - PubMed

CTA identifies active contrast extravasation (the spot sign), which suggests ongoing bleeding and higher expansion risk, and can evaluate for macrovascular lesions. CTA, MRA, MRI, catheter angiography, and venous imaging should be selected according to age, hemorrhage location, hypertension history, atypical CT features, and suspicion for aneurysm, arteriovenous malformation, cavernous malformation, tumor, or cerebral venous thrombosis. MRI is particularly useful for prior hemorrhage, cerebral microbleeds, cerebral amyloid angiopathy markers, and occult structural lesions. Wolters Kluwer+2Wolters KluwerEmergent Management of Intracerebral HemorrhagePubMedHemorrhagic Stroke Overview - StatPearls - NCBI BookshelfPubMed2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association - PubMed

For suspected SAH, CT is the first diagnostic study; aneurysmal SAH requires vascular imaging and urgent neurosurgical/neurointerventional management. The supplied evidence identifies aneurysm, vascular malformation, vasculitis, dissection, venous thrombosis, and pituitary apoplexy among important causes of nontraumatic SAH. PubMed+1PubMedHemorrhagic Stroke Overview - StatPearls - NCBI BookshelfPubMed2023 Guideline for the Management of Patients ... - PubMed

Blood pressure management should avoid both persistent severe hypertension and abrupt overcorrection. The AHA/ASA spontaneous ICH guideline is the principal U.S. reference in the supplied evidence. A contemporary review describes intensive blood pressure control, coagulopathy reversal, and organized hyperacute systems of care as central components of emergent ICH management. Wolters Kluwer+1Wolters KluwerEmergent Management of Intracerebral HemorrhagePubMed2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association - PubMed

Raised intracranial pressure is managed with head elevation, hyperosmolar therapy when clinically indicated, and urgent treatment of hydrocephalus or mass effect. In the setting of impending herniation, brief controlled hyperventilation may be used as a temporizing maneuver while definitive therapy proceeds. PubMedPubMedHemorrhagic Stroke Overview - StatPearls - NCBI Bookshelf

Do not give routine antiseizure prophylaxis to all patients with ICH. Treat clinical or electrographic seizures, and use continuous EEG when unexplained impaired consciousness raises concern for nonconvulsive seizures. PubMedPubMedHemorrhagic Stroke Overview - StatPearls - NCBI Bookshelf

External ventricular drainage is a key intervention when intraventricular hemorrhage causes obstructive hydrocephalus or impaired consciousness. Intraventricular thrombolysis has been studied, but it is not a substitute for prompt CSF diversion when hydrocephalus is clinically significant. Wolters Kluwer+1Wolters KluwerEmergent Management of Intracerebral HemorrhagePubMedHemorrhagic Stroke Overview - StatPearls - NCBI Bookshelf

For spontaneous supratentorial ICH, conventional early open craniotomy has not shown overall benefit in unselected patients. Surgical intervention may nevertheless be lifesaving for deterioration, refractory intracranial hypertension, or substantial mass effect. Recent minimally invasive approaches have evolved; ENRICH reported better 180-day functional outcomes with early minimally invasive removal, particularly in lobar hemorrhage. Wolters Kluwer+1Wolters KluwerEmergent Management of Intracerebral HemorrhagePubMedHemorrhagic Stroke Overview - StatPearls - NCBI Bookshelf

Cerebellar hemorrhage with brainstem compression, hydrocephalus, or neurologic deterioration requires urgent surgical assessment. The supplied evidence identifies urgent evacuation, with or without ventricular drainage, as indicated in these high-risk presentations. PubMed+1PubMedHemorrhagic Stroke Overview - StatPearls - NCBI BookshelfPubMed2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association - PubMed

Important ICH prognostic variables include level of consciousness, age, hematoma volume, infratentorial location, intraventricular extension, hydrocephalus, hematoma expansion, and comorbid illness. The ICH score combines several of these features, but prognostication should incorporate serial examination, imaging evolution, etiology, treatment limitations, and longer recovery trajectories. Wolters Kluwer+2Wolters KluwerEmergent Management of Intracerebral HemorrhagePubMedHemorrhagic Stroke Overview - StatPearls - NCBI BookshelfPubMed2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association - PubMed

For survivors, strict long-term blood pressure control is the dominant modifiable secondary-prevention intervention. Etiologic workup should guide decisions about antithrombotic resumption, management of cerebral amyloid angiopathy risk, treatment of vascular malformations, and counseling about recurrent hemorrhage. PubMed+1PubMedHemorrhagic Stroke Overview - StatPearls - NCBI BookshelfPubMed2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association - PubMed

Early rehabilitation planning, dysphagia assessment, prevention of aspiration and venous thrombosis, and structured follow-up are central to functional outcome. Two-year or early disability measures should not be represented as a fixed ceiling on later recovery. Wolters Kluwer+1Wolters KluwerEmergent Management of Intracerebral HemorrhagePubMedHemorrhagic Stroke Overview - StatPearls - NCBI Bookshelf