Spontaneous Intracerebral Hemorrhage — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Confirm · anticoagulation-related?
   Non-contrast CT confirms spontaneous ICH — is it anticoagulation/antithrombotic-related? (Urgent non-contrast head CT confirms; check CBC, coagulation (PT/APTT/INR) and platelets to clarify anticoagulation or coagulopathy. Concurrently control BP, neuro monitoring, admit to stroke unit/neuro ICU.)
   • Anticoagulation/antithrombotic-related → Reverse anticoagulation immediately
   • Not anticoagulation-related → Stratify by SBP
2. [End] Reverse anticoagulation immediately
   Stop anticoagulants immediately + reverse as fast as possible: warfarin/VKA with INR ≥2.0 → 4-factor prothrombin complex concentrate (4F-PCC, preferred over FFP) + vitamin K; dabigatran → idarucizumab; Xa inhibitors (rivaroxaban/apixaban/edoxaban) → andexanet alfa (4F-PCC if unavailable); heparin → protamine. Concurrently control BP by SBP, neurosurgical assessment. Note: platelet transfusion for antiplatelet users is not beneficial and may be harmful (PATCH).
3. [Decision] Stratify by SBP
   SBP level? (Smooth, sustained BP control reduces hematoma expansion and improves outcome.)
   • SBP 150–220 → SBP 150–220
   • SBP >220 or large / surgical → SBP >220 / large / surgical
4. [End] SBP 150–220
   Mild–moderate ICH: acutely lower BP to a target of 140 (maintain 130–150), start within 2 h, control smoothly, limit BP variability; avoid lowering to <130 (possibly harmful). Neuro monitoring, glucose and temperature control, VTE prophylaxis (early pneumatic compression), neurosurgical assessment if needed.
5. [End] SBP >220 / large / surgical
   Continuous IV antihypertensive infusion, lower BP cautiously under close monitoring (evidence for intensive lowering is limited; avoid too fast/too low); manage intracranial pressure (head elevation, analgesia/sedation, hyperosmolar therapy and surgery if needed); neurosurgical assessment — cerebellar hemorrhage with deterioration/brainstem compression/hydrocephalus → hematoma evacuation or external ventricular drain.

Source guidelines & references

• AHA/ASA 2022 Guideline for the management of spontaneous intracerebral hemorrhage. Stroke 2022;53:e282-e361

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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