Intracerebral Hemorrhage Management (AHA/ASA 2022)

Algorithm Steps

1. ▶

   Start

   START: Intracerebral Hemorrhage

   CT confirms spontaneous ICH

   1. ●

      Action

      Initial Assessment

      Rapid evaluation

      • ABC stabilization, protect airway if GCS ≤8
      • Stat CT head (non-contrast)
      • Labs: CBC, BMP, coags (PT/INR, PTT), type & screen
      • Determine anticoagulant/antiplatelet use
      • ICH Score for prognosis
      1. ◆

         Decision

         On Anticoagulation?

         Check for coagulopathy

         1. ⚠

            Warning

            URGENT Anticoagulant Reversal

            Reverse immediately

            • WARFARIN: 4-factor PCC 25-50 units/kg + Vitamin K 10mg IV
            • Target INR ≤1.3 within 4 hours
            • DABIGATRAN: Idarucizumab 5g IV
            • RIVAROXABAN/APIXABAN: Andexanet alfa or 4-factor PCC
            • HEPARIN: Protamine sulfate
            • DO NOT DELAY for INR result if known warfarin use
            1. ●

               Action

               Blood Pressure Management

               Rapid lowering to target

               • TARGET: SBP 130-150 mmHg (INTERACT2)
               • If SBP 150-220: Lower to 140 is safe and may improve outcomes
               • If SBP >220: Aggressive reduction with continuous monitoring
               • AGENTS: Nicardipine, Labetalol, Clevidipine infusion
               • Avoid large fluctuations
               1. ●

                  Action

                  Prevent Hematoma Expansion

                  Key modifiable factor

                  • Early BP control (within 2 hours)
                  • Reversal of coagulopathy
                  • CTA spot sign predicts expansion
                  • Consider TXA if <4.5 hrs (TICH-2: modest benefit)
                  1. ◆

                     Decision

                     Surgical Evacuation Indicated?

                     Evaluate for surgery

                     • CONSIDER SURGERY: Cerebellar ICH >3cm with deterioration, hydrocephalus, or brainstem compression
                     • Supratentorial: Lobar ICH >30mL, within 1cm of surface, with deterioration
                     • EVD for hydrocephalus with decreased consciousness
                     • AVOID SURGERY: Deep ICH, small hemorrhages, stable patients
                     1. ●

                        Action

                        Surgical Intervention

                        Neurosurgical management

                        • Cerebellar: Suboccipital craniectomy
                        • Supratentorial: Craniotomy or minimally invasive approaches
                        • EVD for hydrocephalus
                        • Decompressive craniectomy if refractory ICP
                        1. ●

                           Action

                           ICU Management

                           Supportive care

                           • Neuro ICU admission
                           • Frequent neuro checks
                           • ICP monitoring if GCS ≤8 or declining
                           • Target ICP <20 mmHg, CPP 60-70 mmHg
                           • DVT prophylaxis (SCD initially, then pharmacologic after 24-48h)
                           • Seizure prophylaxis NOT routine (treat if occur)
                           • Glucose control, fever prevention
                           1. ●

                              Action

                              Prognosis & Goals of Care

                              Avoid early WLST

                              • ICH Score for prognostication
                              • AVOID withdrawal of care in first 24-48 hours
                              • Early aggressive DNR may worsen outcomes
                              • Multidisciplinary family meeting
                              1. ✓

                                 Outcome

                                 Ongoing Management

                                 Rehabilitation and secondary prevention

                                 • Early rehabilitation
                                 • BP control long-term
                                 • Anticoagulation decision after recovery
                                 • Evaluate for underlying vascular malformation