Intracerebral Hemorrhage

• Immediately reverse anticoagulation: PCC + vitamin K for warfarin, idarucizumab for dabigatran, andexanet or PCC for Xa inhibitors.
• Rapid, smooth reduction toward ~SBP 140 in appropriate patients, avoiding hypotension — do not drive below 130; ICP measures for mass effect; EVD for hydrocephalus.
• Surgery for cerebellar bleeds >3 cm with deterioration; STITCH trials make supratentorial cases selective.
• Give seizure prophylaxis only after a seizure or with cortical lobar bleeds; restart anticoagulation case-by-case (~7–8 wk for AF in lobar ICH).

Approach to Suspected Intracranial Hemorrhage

• Intracranial hemorrhage suspected: acute neurological symptoms · ± altered level of consciousness · ± headache · ± nausea/vomiting
• Stability check: airway · breathing · circulation
• Brief neurological assessment & history: ? CAD, HTN · anticoagulant use · prior stroke, TIA, ICH · illicit drug use · recent head trauma
• Emergent head CT ± CT-A head
• ICH present?
• Active blood pressure management
• Correct coagulopathy (Table 54.2)
• ICP management
• Weigh need for surgical intervention (Table 54.3)
• Admit to Neuro ICU
• Work up other etiologies