| Clinical features |
- Stroke symptoms: sudden onset loss of function in speech, vision, movement, sensation, balance
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- Features suggestive of ICH over ischemic stroke: progressive worsening of acute symptoms; severely elevated SBP (eg, >220 mmHg); patient taking anticoagulant
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- Signs of elevated ICP (mass effect from ICH):
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- Cushing triad (bradycardia, respiratory depression, hypertension)
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| Evaluation |
- Assess airway, breathing, circulation, and disability to initiate supportive care
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- Determine GCS, neurologic deficits
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- Obtain emergency imaging (eg, head CT or fast MRI)
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- Initial laboratory evaluation: complete blood count, PT, PTT, INR, basic electrolytes, glucose, cardiac-specific troponin, pregnancy test in females of childbearing age
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- Serial monitoring (hourly) for neurologic deterioration or signs of elevated ICP
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| Treatment* |
- Perform tracheal intubation for any patient unable to protect their airway or with rapidly deteriorating mental status or GCS ≤8
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- Obtain immediate neurosurgical consultation for imaging findings indicating need for emergency surgery:
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- Cerebellar ICH that is either ≥3 cm3 diameter or causing brainstem compression
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- IVH with obstructive hydrocephalus and neurologic deterioration
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- Hemispheric ICH with life-threatening brain compression or obstructive hydrocephalus
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- Reverse anticoagulation (agent specific):
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- Warfarin (4-factor PCC with IV vitamin K)
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- Dabigatran (idaricizumab)
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- Factor Xa inhibitors: apixaban, edoxaban, rivaroxaban (4-factor PCC or andexanet alfa)
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- Unfractionated heparin (protamine sulfate)
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- Low molecular weight heparin (andexanet alfa; protamine sulfate is an alternative)
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- Immediate treatment to reduce SBP below 220 mmHg: nicardipine starting at 5 mg/hour IV; alternate: labetalol 20 mg IV bolus, may repeat every 10 minutes
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- Subsequent, stepwise treatment, typically over first 1 to 2 hours, to reduce SBP to 140 to 160 mmHg; monitor for neurologic deterioration
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- Manage elevated intracranial pressure:
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- General preventive measures:
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- Elevate head of bed >30 degrees
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- Give mild sedation as needed for comfort for intubated patients (eg, midazolam)
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- Give antipyretics for temperature >38°C (eg, acetaminophen [paracetamol] 325 to 650 mg orally or PR every 4 to 6 hours or 650 mg IV every 4 hours)
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- Maintain neutral head positioning; avoid rotating the neck or placing IV lines or devices in or at the neck that may impede venous outflow
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- Use isotonic solutions for volume resuscitation and maintenance fluids; maintain serum sodium >135 mEq/L
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- Repeat imaging (eg, head CT) for neurologic deterioration or signs of elevated ICP:
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- Obtain immediate neurosurgical consultation for surgical indications (refer to above)
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- Give osmotic therapy via central venous catheter for clinical signs or imaging findings of elevated ICP:
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- Hypertonic saline 23.4%: 15 to 30 mL IV bolus every 6 hours, or
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- Mannitol: 0.25 to 1 g/kg IV bolus every 6 hours
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