Acute Intraparenchymal Hemorrhage Management

Acute Spontaneous Intracerebral Hemorrhage

Diagnose the Hemorrhage and Its Cause

Obtain emergency noncontrast CT while stabilizing airway, oxygenation, circulation, and glucose. Record onset or last known well, neurologic examination, baseline function, antithrombotic medications, recent procedures, trauma, hypertension, substance exposure, and bleeding history. Look for ventricular extension, hydrocephalus, posterior fossa involvement, mass effect, and herniation. Repeat imaging according to the early course and immediately for deterioration. A stable first scan does not exclude subsequent expansion.

Deep basal ganglia, thalamic, pontine, or cerebellar hemorrhage commonly reflects hypertensive small-vessel disease. Lobar hemorrhage in an older adult raises concern for cerebral amyloid angiopathy, but location alone does not prove the cause. Anticoagulation, vascular malformation, aneurysm, venous thrombosis, tumor, hemorrhagic transformation, and other mechanisms must be considered. Use vascular imaging, selected catheter angiography, and MRI according to age, location, risk factors, and the initial findings. A seemingly typical location does not make every secondary investigation unnecessary.

CAA involves amyloid deposition in cortical and leptomeningeal vessels and is associated with lobar hemorrhage, strictly lobar microbleeds, and cortical superficial siderosis. Boston v2.0 clinical categories combine age, presentation, imaging, and exclusion of other causes; mixed deep and lobar lesions complicate classification. Deep hemorrhagic lesions preclude particular probable-CAA imaging categories, but that does not prove that mixed small-vessel pathology cannot coexist biologically.

Blood Pressure and General Stabilization

The 2022 AHA/ASA guideline supports smooth, sustained pressure control with avoidance of large variability. For mild-to-moderate ICH presenting with SBP 150–220 mm Hg, targeting 140 and maintaining 130–150 is reasonable. Lowering below 130 in this setting is potentially harmful. The safety and benefit of intensive lowering are less established in large or severe hemorrhage, surgical decompression, and other presentations. Marked hypertension above 220 requires careful individualized management rather than an automatic identical target.

Nicardipine, clevidipine, or appropriately selected labetalol can provide titratable treatment. Agent choice depends on heart rate, cardiac function, airway disease, access, and local protocol. A continuous infusion is useful for sustained control, but not every bolus is categorically prohibited. Verify cuff and arterial measurements, avoid overshoot during sedation or intubation, and evaluate kidney function and systemic perfusion.

INTERACT2 had a neutral primary dichotomous endpoint with a favorable ordinal outcome signal. ATACH-2 did not improve death or disability with its more intensive strategy and reported more renal adverse events. Neither trial proves a single universal physiologic cliff at an exact SBP. INTERACT3 supported a coordinated care bundle involving pressure, glucose, temperature, and reversal rather than attributing the entire outcome to one component. Avoid severe hyperglycemia and hypoglycemia, treat fever and its cause, perform dysphagia assessment, and arrange appropriate nursing and rehabilitative care.

Measure Severity Without Creating Certainty

The ICH score assigns points for GCS 3–4 (two) or 5–12 (one), volume at least 30 mL (one), IVH (one), infratentorial origin (one), and age at least 80 (one). For example, a 74-year-old with GCS 10, a 36-mL thalamic hemorrhage, and IVH has three points: one each for GCS, volume, and IVH. The thalamus is supratentorial and age contributes zero.

The ABC/2 method estimates volume from greatest diameter A, perpendicular diameter B on the same slice, and approximate craniocaudal extent C. With dimensions 4, 3, and 5 cm, the estimate is 30 mL. Irregular, multilobulated, or heterogeneous hemorrhage can make this approximation inaccurate; use appropriate imaging measurement when precision matters. A CTA spot sign supports concern for expansion but does not by itself mandate an operation or justify empiric reversal in a patient without the relevant drug exposure.

Original cohort mortality estimates are group observations, not calibrated promises for an individual in contemporary care. Do not use a severity score alone to limit treatment. Sedation, hydrocephalus, seizures, organ failure, and subsequent response can change the assessment. Discuss uncertainty and known preferences early while continuing indicated stabilization.

Reverse Relevant Coagulopathy Promptly

Stop the offending anticoagulant and provide urgent drug-appropriate treatment. For warfarin-associated ICH, 4F-PCC provides faster factor replacement with less volume than plasma, and IV vitamin K supports sustained correction. Use the current INR/weight or validated institutional regimen and repeat testing. Vitamin K is infused slowly according to product instructions; it is not an undiluted rapid push. Plasma remains an option when PCC is unavailable and requires attention to transfusion risks.

Idarucizumab is specific to dabigatran. For factor-Xa inhibitors, current US availability matters: the FDA reported serious thrombotic concerns and US andexanet sales ended December 22, 2025. PCC-based nonspecific strategies are commonly used under current institutional guidance; they do not remove the drug or necessarily normalize anti-Xa activity. Normal INR, aPTT, or routine viscoelastic results do not reliably exclude clinically important DOAC exposure. Include dose timing, kidney function, drug-specific assays when available, thrombosis risk, and urgent specialist input.

Protamine reverses unfractionated heparin and incompletely reverses low-molecular-weight heparin; dosing depends on agent, amount, and elapsed time. Platelet transfusion is harmful for aspirin-associated spontaneous ICH without emergency surgery in the population addressed by the guideline. Surgical circumstances and thrombocytopenia require separate assessment. The effectiveness of desmopressin for antiplatelet-associated ICH remains uncertain. Do not transfer PATCH findings indiscriminately to every agent, procedure, or platelet disorder.

Sources: 2022 AHA/ASA ICH guideline and FDA andexanet safety update.

Decision Review