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Intracerebral Hemorrhage Management (AHA/ASA 2022)

Intracerebral Hemorrhage Management (AHA/ASA 2022): START: Intracerebral Hemorrhage → Initial Assessment → On Anticoagulation? → URGENT Anticoagulant Re...

Pathway Overview

11 steps

Algorithm Steps

11 total

  1. 01Start

    START: Intracerebral Hemorrhage

    CT confirms spontaneous ICH

  2. 02Action

    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
  3. 03Decision

    On Anticoagulation?

    Check for coagulopathy

  4. 04Warning

    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
  5. 05Action

    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
  6. 06Action

    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)
  7. 07Decision

    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
  8. 08Action

    Surgical Intervention

    Neurosurgical management

    • Cerebellar: Suboccipital craniectomy
    • Supratentorial: Craniotomy or minimally invasive approaches
    • EVD for hydrocephalus
    • Decompressive craniectomy if refractory ICP
  9. 09Action

    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
  10. 10Action

    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
  11. 11Outcome

    Ongoing Management

    Rehabilitation and secondary prevention

    • Early rehabilitation
    • BP control long-term
    • Anticoagulation decision after recovery
    • Evaluate for underlying vascular malformation
  12. Path rejoins step 09Shared downstream outcome
  13. Path rejoins step 05Shared downstream outcome

Guideline Source

AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage

DOI: 10.1161/STR.0000000000000407View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Anticoagulant reversal agents evolve rapidly
  • BP targets are based on INTERACT2/ATACH-2 trials
  • Surgical indications vary by institution
  • ICP monitoring practices vary

Contraindicated Populations

pediatric

Applicable Regions

USEUGlobal

US: AHA/ASA 2022 is current standard

Version 1Next review: 2027-01-01

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Frequently Asked Questions

What is the Intracerebral Hemorrhage Management (AHA/ASA 2022)?

The Intracerebral Hemorrhage Management (AHA/ASA 2022) is a emergency clinical algorithm for Emergency Medicine. It provides a structured decision tree to guide clinical decision-making, based on AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage.

What guideline is the Intracerebral Hemorrhage Management (AHA/ASA 2022) based on?

This algorithm is based on AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage (DOI: 10.1161/STR.0000000000000407).

What are the limitations of the Intracerebral Hemorrhage Management (AHA/ASA 2022)?

Known limitations include: Anticoagulant reversal agents evolve rapidly; BP targets are based on INTERACT2/ATACH-2 trials; Surgical indications vary by institution; ICP monitoring practices vary. Individual patient factors may require deviation from these recommendations.

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