Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Rapid CT; control BP; reverse anticoagulation immediately.
- Neurosurgical triage (posterior fossa/large lobar); manage ICP and airway.
- Monitor with repeat imaging; secondary prevention and rehab planning.
Clinical Synopsis & Reasoning
Nontraumatic ICH requires rapid BP control (often SBP 140–160), urgent reversal of anticoagulants, and neurocritical care. Identify candidates for neurosurgical intervention (posterior fossa, large lobar with mass effect) and manage ICP/airway; avoid hyperglycemia and fever.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/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 |
|---|
| Noncontrast head CT ± CTA | Diagnosis | Localize bleed; spot sign | — |
| Coagulation labs/anticoagulant levels | Reversal planning | Guide targeted reversal | — |
| Neuro exam and GCS; repeat imaging | Monitoring | Expansion detection | — |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| GCS ≤8, expanding hematoma, or hydrocephalus | High mortality | ICU; neurosurgery; EVD if needed |
| Anticoagulant-associated bleed | Expansion risk | Immediate reversal (PCC/idarucizumab/andexanet as appropriate) |
| SBP >200 mmHg or MAP >150 | Hematoma expansion | Rapid BP control |
| Posterior fossa hemorrhage | Brainstem compression | Urgent neurosurgical evaluation |
| Seizures or refractory ICP | Secondary injury | Anticonvulsants; ICP management |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| BP control with Nicardipine/Clevidipine/Labetalol | Antihypertensives | Minutes | Limit expansion | Frequent monitoring |
| Reversal: PCC for warfarin; Idarucizumab for dabigatran; Andexanet alfa for apixaban/rivaroxaban | Hemostasis | Immediate | Reduce hematoma expansion | Institutional protocols |
| Hyperosmolar therapy (mannitol/hypertonic saline) for ICP | ICP management | Minutes | Temporize herniation | Neurosurgery/EVD if needed |
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
- AHA/ASA ICH guidelines — Link