Intracerebral Hemorrhage: BP Targets, Reversal & Neurosurgical Triggers

Intracerebral hemorrhage (ICH) kills by hematoma expansion, mass effect/ICP, and secondary injury. Time-sensitive moves: lower blood pressure safely, reverse anticoagulation, and call neurosurgery early for hydrocephalus or surgical lesions—while delivering tight ICU care.

Step 1 — Recognize & Image Fast

• Symptoms: sudden focal deficit, headache, vomiting, decreased level of consciousness, seizures.
• Non-contrast CT head immediately (diagnoses ICH and size/location; look for IVH).
• Consider CT angiography to evaluate spot sign (expansion risk) and secondary causes (AVM/aneurysm, tumor, vasculopathy).

Step 2 — Airway, Breathing, Circulation (with BP focus)

• Airway protection if GCS low or uncontrolled emesis; avoid routine hyperventilation (only brief bridge for herniation).
• BP target: rapidly lower SBP to ~140–160 mmHg (individualize; avoid dropping MAP too far in chronic hypertensives). Use titratable IV agents:
  • Nicardipine infusion or clevidipine as first-line.
  • Labetalol IV boluses acceptable in mild–moderate hypertension.
  • Avoid large BP swings; reassess neuro status with each titration.

Step 3 — Immediate Anticoagulant/Antiplatelet Reversal

Do this in parallel with BP control—every minute matters.

• Warfarin/VKA: 4-factor PCC (weight/INR-based) + 10 mg IV vitamin K (slow IV). Avoid FFP delays unless PCC unavailable.
• Dabigatran: idarucizumab 5 g IV. If unavailable, consider PCC and dialysis in renal failure.
• Factor Xa inhibitors (apixaban/rivaroxaban/edoxaban): andexanet alfa per label if available; otherwise use 4-factor PCC (e.g., 50 U/kg) per local protocol.
• Antiplatelet agents: routine platelet transfusion is not recommended in spontaneous ICH on aspirin/clopidogrel without surgery; discuss with neurosurgery if an urgent operation is planned. Consider DDAVP 0.3 mcg/kg IV once for suspected platelet dysfunction (uremia/antiplatelets) per local practice.
• Fibrinolytics (tPA-related ICH): cryoprecipitate to correct fibrinogen and/or tranexamic acid per protocol.

Step 4 — Intracranial Pressure (ICP) & Neurocritical Care

• Head of bed 30°, neutral neck, treat pain/agitation (short-acting agents), maintain normoxia/normocapnia.
• Osmotic therapy for herniation or refractory ICP: hypertonic saline (3% bolus/infusion) or mannitol (if euvolemic and kidneys OK). Monitor sodium/osmolality.
• Seizures: no routine prophylaxis; treat clinical/subclinical seizures. Use EEG if mental status is unexplained.
• Temperature & glucose: avoid fever; target glucose roughly 140–180 mg/dL; avoid hypoglycemia.
• DVT prophylaxis: pneumatic compression early; chemoprophylaxis after hematoma stability (often 24–48 h post-stable scan) per neurosurgery.

Step 5 — Who Needs a Neurosurgeon Now?

• Cerebellar hemorrhage (≈>3 cm), neurologic deterioration, brainstem compression, or hydrocephalus → urgent surgical decompression.
• Lobar hematomas with progressive decline or superficial location may be considered for evacuation in select patients.
• Intraventricular hemorrhage (IVH) with obstructive hydrocephalus → external ventricular drain (EVD).
• Large deep ganglionic bleeds are typically managed medically unless life-threatening mass effect—consult early regardless.

Etiology Workup (after stabilization)

• Hypertensive arteriopathy (deep ganglia, thalamus, pons, cerebellum) vs cerebral amyloid angiopathy (lobar, elderly).
• Coagulopathy/antithrombotics, tumor, vascular malformation, venous sinus thrombosis, vasculitis, drug use (sympathomimetics).
• CTA/MRA, MR with GRE/SWI for microbleeds when stable; venography if CVST suspected.

Blood Pressure After the First Hours

• Maintain SBP generally 130–150 (individualize to exam and ICP considerations). Avoid rebound hypertension and hypotension.

Restarting Antithrombotics (individualize)

• Antiplatelet for strong vascular indications may be restarted after hematoma stability and risk discussion (often days–weeks).
• Anticoagulation after ICH is complex—timing depends on lobar vs deep ICH, indication (AF with high CHA₂DS₂-VASc, mechanical valve, VTE), and recurrence risk; typical ranges are weeks to months with specialist input.

Secondary Prevention

• Long-term BP control (often <130/80), avoid heavy alcohol, manage lipids, diabetes, and sleep apnea.
• In amyloid angiopathy, minimize antithrombotic exposure where possible; counsel on recurrent bleed risk.

Pearls & Pitfalls

• Start BP lowering and reversal in parallel—don’t sequence them.
• Avoid hypotension—ischemia worsens outcomes.
• Early neurosurgery call for cerebellar bleeds, hydrocephalus, or any deterioration—even if the initial plan is medical.

Patient FAQs

“Can the bleeding spread if my pressure is high?” Yes—tight but safe BP control helps prevent expansion.

“Why can’t I restart my blood thinner now?” We balance stroke-prevention benefits against rebleed risk; timing depends on bleed location and your underlying condition.

References & Notes

Practical ICH pathway: rapid SBP control (~140–160), immediate reversal of anticoagulation, ICU-level neuro care with ICP measures, and early surgical/EVD decisions for cerebellar bleeds, hydrocephalus, or decline. Local protocols vary—follow institutional guidance. Educational only.