Intracerebral Hemorrhage

• Immediately reverse anticoagulation: PCC + vitamin K for warfarin, idarucizumab for dabigatran, 4-factor PCC for Xa inhibitors (andexanet was withdrawn from the US market in December 2025).
• Rapid, smooth reduction toward ~SBP 140 in appropriate patients, avoiding hypotension — do not drive below 130; ICP measures for mass effect; EVD for hydrocephalus.
• Cerebellar ICH: urgent evacuation ± EVD for neurological deterioration, brainstem compression, obstructive hydrocephalus or volume ≥15 mL. Supratentorial surgery is decided case by case.
• Treat clinical or EEG seizures, but give no routine seizure prophylaxis — lobar ICH included. Restart anticoagulation case by case; for AF, around 7–8 weeks may be considered after weighing rebleeding against stroke risk.

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?
• Yes
• Active blood pressure management
• Reverse anticoagulation now, drug by drug — doses are in Pathway 27.2 and the Treatment popup.
• ICP management
• Deterioration, mass effect or hydrocephalus: call neurosurgery now. Cerebellar evacuation criteria are in Pathway 27.2.
• Admit to Neuro ICU
• No
• Work up other etiologies

The Acute Intracerebral Hemorrhage Care Bundle

• Confirmed ICH: handle airway and GCS, BP, anticoagulant reversal, glucose, fever and neurosurgical review all at once. INTERACT3 glucose targets: 6.1–7.8 mmol/L without diabetes, 7.8–10 with diabetes; avoid hypoglycaemia. Treat temperature >37.5 °C.
• Mild–moderate ICH with SBP 150–220: bring SBP smoothly to 140 and hold it at 130–150 mm Hg with a titratable IV drug. Avoid SBP <130 and big sudden drops. In large or severe ICH, raised ICP or before surgery, set the target case by case to protect cerebral perfusion.
• On an anticoagulant?
• Yes
• Vitamin K antagonist → 4-factor prothrombin complex concentrate 25–50 U/kg by INR, plus vitamin K 10 mg IV; recheck INR at 15–30 minutes, targeting below 1.3
• Factor Xa inhibitor → 4-factor PCC 50 U/kg; andexanet alfa only where still available (withdrawn from the US market in December 2025). Dabigatran → idarucizumab 5 g IV. Heparin → protamine. Antiplatelet alone → do not transfuse platelets, which increased death and dependence in the PATCH trial, unless neurosurgery is planned
• No
• Check the platelet count and coagulation screen anyway, correct a platelet count below 50 × 10⁹/L, and look for the acquired coagulopathy of liver disease, sepsis or renal failure
• Cerebellar ICH ≥15 mL, neurological deterioration, brainstem compression or obstructive hydrocephalus?
• Yes
• Urgent neurosurgical evacuation of the cerebellar haematoma, plus an EVD if hydrocephalus needs it. An EVD alone does not replace evacuation when it is indicated.
• No
• Manage in a neuro-ICU or stroke unit: 30° head-up, normocapnia, analgesia and antiemesis, treat clinical or electrographic seizures but give no prophylactic antiepileptic, and repeat CT if the neurology changes
• Respect the patient's known wishes and directives. If there were none, do not start new DNAR or withdrawal decisions before the second full hospital day — keep treating and reassess. Start pneumatic compression on day 1; consider low-dose heparin at 24–48 h once the bleed is stable.