Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets (hemodynamic, neurologic, respiratory) and reassess frequently.
- Plan definitive source control or reperfusion when indicated; document follow‑up and patient education.
Algorithm
- Diagnose by CT; activate stroke/neurocritical pathways.
- Lower BP promptly (e.g., SBP to 140–160 in many cases); avoid hypotension.
- Reverse anticoagulation: 4F-PCC for warfarin; andexanet or PCC for factor Xa inhibitors; idarucizumab for dabigatran.
- Consult neurosurgery for cerebellar hemorrhage, large lobar bleeds, or deterioration; consider EVD for hydrocephalus.
- ICU monitoring: neuro checks, repeat CT, DVT prophylaxis with IPC early; start pharmacologic when safe.
Clinical Synopsis & Reasoning
Urgent BP reduction, reversal of anticoagulation, neurosurgical consultation for select cases, and neurocritical monitoring. Consider hematoma expansion risk and spot sign; manage glucose, temperature, and DVT prophylaxis appropriately.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced or procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| Non-contrast head CT | Diagnosis | Acute hemorrhage | Baseline for expansion |
| CTA with spot sign (selected) | Expansion risk | Spot sign positive | Prognostic |
| Coagulation labs/anticoagulant history | Reversal planning | Elevated INR/DOAC timing | Reversal choice based on agent |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Nicardipine/Clevidipine infusion | Antihypertensive | Minutes | Target SBP 140–160 (context-dependent) | Avoid hypotension |
| 4F-PCC (50 U/kg) or Andexanet alfa | Reversal agents | Immediate | Reverse warfarin/FXa inhibitors | Thrombosis risk/cost |
| Insulin protocol/antipyretics | Supportive | Hours | Glucose/fever control | Avoid hypoglycemia |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- 2022 AHA/ASA Guideline for Spontaneous ICH — Link