Intracerebral haemorrhage (ICH)

Learning objectives

Learning
Understand
Integrate
Reflect

Link to RCP Stroke Guidelines 2016

General Advice

Patients with ICH in association with vitamin K antagonist treatment should have the anticoagulant urgently reversed with a combination of PCC and IV vitamin K.
Patients with ICH in association with dabigatran treatment should have the anticoagulant urgently reversed with idarucizumab.
Patients with ICH in association with factor Xa inhibitor treatment should receive urgent treatment with 4-factor PCC.

ICH and BP

Patients with primary ICH who present within 6 hours of onset with a systolic blood pressure above 150mmHg should be treated urgently using a locally agreed protocol for blood pressure lowering to a systolic blood pressure of 140 mmHg for at least 7 days, unless:

the Glasgow Coma Scale score is 5 or less;
the haematoma is very large and death is expected;
a structural cause for the haematoma is identified;
immediate surgery to evacuate the haematoma is planned.

ICH and Hydrocephalus

Patients with ICH should be admitted directly to a HASU for monitoring of conscious level and referred immediately for repeat brain imaging if deterioration occurs.
Patients with ICH who develop hydrocephalus should be considered for surgical intervention such as insertion of an external ventricular drain.

Surgery

Acute stroke services should have protocols for the monitoring, referral and transfer of patients to regional neurosurgical centres for decompressive hemicraniectomy, surgical management of intracranial haemorrhage and the management of symptomatic hydrocephalus including external ventricular drain insertion