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Neurology · Topic 3 of 22

Intracerebral Hemorrhage

Neurology · hemorrhagic stroke

Intracerebral Hemorrhage

Bleeding into brain tissue: lower SBP to 130–139 quickly, reverse any anticoagulant at once, and evacuate cerebellar clots that threaten the brainstem.

Key numbers
SBP 150–220: lower to 130–139 mmHgSBP 130–< 140
Warfarin ICH: 4F-PCC plus vitamin KINR ≥ 2 → 4F-PCC
Cerebellar ICH ≥ 15 mL: evacuate nowCerebellar ≥ 15 mL
01 · Defined bySBP 150–220: lower to 130–139 mmHg

With SBP 150–220 mmHg, lower SBP promptly to 130–< 140 mmHg — start within 2 hours, reach target within 1 hour — and keep it smooth for at least 7 days; avoid < 130.

02 · GiveWarfarin ICH: 4F-PCC plus vitamin K

Stop the anticoagulant and reverse at once: for warfarin with INR ≥ 2.0, give 4-factor PCC (preferred over FFP) followed directly by IV vitamin K; earlier reversal to INR < 1.3 limits hematoma expansion.

03 · DoCerebellar ICH ≥ 15 mL: evacuate now

Cerebellar hemorrhage with neurologic deterioration, brainstem compression, hydrocephalus or volume ≥ 15 mL needs immediate surgical evacuation, with or without an EVD; an EVD alone is potentially harmful.

01

Causes & risk factors

Why it happens
Lobar bleed in an older adult: amyloid angiopathyDeep hemorrhages (putamen, thalamus, pons, cerebellum) are typically hypertensive; lobar hemorrhages in older adults suggest cerebral amyloid angiopathy, which tends to recur.
02

Diagnosis & monitoring

Work-up
ICH score estimates mortalityICH score: GCS 3–4 (2) or 5–12 (1), volume ≥ 30 mL (1), intraventricular blood (1), infratentorial origin (1), age ≥ 80 (1); use it to communicate, never as the sole reason to limit care.
03

Do right now

In this order
First moves
1
Noncontrast CT to confirm hemorrhage
→
2
SBP 150–220: lower to 130–139 mmHgSBP 130–< 140
→
3
Warfarin ICH: 4F-PCC plus vitamin KINR ≥ 2 → 4F-PCC
→
4
DOAC ICH: idarucizumab or 4-factor PCC
→
5
Cerebellar ICH ≥ 15 mL: evacuate nowCerebellar ≥ 15 mL
Why each step
Noncontrast CT to confirm hemorrhageSudden focal deficit with headache, vomiting and falling consciousness suggests ICH, but only imaging separates it from infarction: get an immediate noncontrast CT (or MRI) plus bedside glucose, CBC, INR and PTT.
SBP 150–220: lower to 130–139 mmHgWith SBP 150–220 mmHg, lower SBP promptly to 130–< 140 mmHg — start within 2 hours, reach target within 1 hour — and keep it smooth for at least 7 days; avoid < 130.
Warfarin ICH: 4F-PCC plus vitamin KStop the anticoagulant and reverse at once: for warfarin with INR ≥ 2.0, give 4-factor PCC (preferred over FFP) followed directly by IV vitamin K; earlier reversal to INR < 1.3 limits hematoma expansion.
DOAC ICH: idarucizumab or 4-factor PCCDabigatran: idarucizumab 5 g IV. Apixaban or rivaroxaban: 4-factor PCC — andexanet alfa, listed in the 2022 guideline, was withdrawn from the US market in December 2025 after excess thrombosis.
Cerebellar ICH ≥ 15 mL: evacuate nowCerebellar hemorrhage with neurologic deterioration, brainstem compression, hydrocephalus or volume ≥ 15 mL needs immediate surgical evacuation, with or without an EVD; an EVD alone is potentially harmful.
04

Management

Orders
Heparin ICH: give IV protamineReverse unfractionated heparin with IV protamine; protamine only partially reverses low-molecular-weight heparin.
Pneumatic compression day 1; heparin at 24–48 hStart intermittent pneumatic compression on the day of diagnosis; low-dose UFH or LMWH prophylaxis may begin 24–48 hours after onset. Compression stockings alone are not effective.
Treat hypoglycemia and glucose above 180Monitor glucose; treat hypoglycemia (< 40–60 mg/dL) and moderate-to-severe hyperglycemia (> 180–200 mg/dL).
Minimally invasive evacuation for mid-size clotsSupratentorial ICH > 20–30 mL with GCS 5–12: minimally invasive evacuation can reduce mortality; ENRICH (lobar 30–80 mL, within 24 hours) also improved function, prompting a 2026 AHA science advisory.
05

Red flags & don'ts

Avoid harm
Hematoma expansion in the first hours complicationHematoma expansion happens mostly in the first hours and drives early deterioration; a CTA spot sign (contrast leaking into the clot) predicts expansion and a poor outcome.
No platelet transfusion for antiplatelet ICH avoidDo not transfuse platelets for ICH on antiplatelet drugs unless emergency neurosurgery is planned; outside surgery or severe thrombocytopenia, platelet transfusion worsens outcome.
Hydrocephalus from IVH: place an EVD complicationIntraventricular extension can cause acute hydrocephalus, an independent predictor of poor outcome; an external ventricular drain rapidly lowers ICP and reduces mortality.
No prophylactic antiseizure drugs or steroids avoidTreat clinical seizures and use continuous EEG for unexplained or fluctuating mental status, but do not give prophylactic antiseizure medication or corticosteroids — neither improves outcome.
06

More detail

Reference
Show 7 reference facts
Look for a macrovascular cause (CTA, MRA or catheter angiography) in younger patients, lobar or cerebellar bleeds, and patients without hypertension.
4-factor PCC is dosed by INR and weight (25–50 IU/kg) or as a fixed dose; for warfarin ICH with INR 1.3–1.9, PCC is reasonable at a lower dose.
Activated charcoal is reasonable if a DOAC was taken within the previous few hours; if idarucizumab is unavailable, PCC or dialysis can lower dabigatran effect.
In AF after ICH, restarting anticoagulation about 7–8 weeks after the bleed may be considered; left atrial appendage closure is an option for patients who cannot be anticoagulated.
For ICP or cerebral edema in ICH, the Neurocritical Care Society suggests hypertonic saline over mannitol; prophylactic or continuous hyperosmolar therapy has no outcome benefit.
Aggressive mobilization within the first 24 hours after ICH worsens 14-day mortality; light rehabilitation may start at 24–48 hours in moderate ICH.
Long term after ICH, keep BP < 130/80 mmHg and avoid regular NSAID use, which raises recurrence risk.
Pearl

The clot grows in the first hours: drop the pressure, reverse the drug, and watch the posterior fossa.

Sources · Greenberg SM et al. 2022 AHA/ASA Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage. Stroke 2022;53:e282–e361 (full-text PDF copy) · Merck Manual Professional — Intracerebral Hemorrhage (updated Dec 2025) · Blood pressure management in stroke: comparative review of the 2025 AHA/ACC, 2024 ESC, 2023 ESH and 2025 JSH guidelines. Hypertens Res 2026 · UMEM Educational Pearls (Univ. of Maryland) — Andexxa Withdrawn from US Market (Feb 2026; cites FDA Safety Communication Dec 18, 2025) · MDCalc — Intracerebral Hemorrhage (ICH) Score · Pradilla G et al. Trial of Early Minimally Invasive Removal of Intracerebral Hemorrhage (ENRICH). N Engl J Med 2024 — abstract via Europe PMC · Evidence Update for Minimally Invasive Surgical Evacuation of Supratentorial Spontaneous ICH: AHA Science Advisory. Stroke 2026 — abstract via Europe PMC · Cook AM et al. Guidelines for the Acute Treatment of Cerebral Edema in Neurocritical Care Patients (Neurocritical Care Society). Neurocrit Care 2020 · TCTMD — Andexanet Alfa Pulled From US Market (Dec 22, 2025; FDA: risks outweigh benefits, AstraZeneca withdrew the BLA) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).