ICH · Hemorrhagic Stroke

Hemorrhagic stroke (ICH)
Time-critical — BP control + reversal first

Suspect ICH with sudden severe HA, vomiting, ↓LOC, or focal deficit + SBP ≥ 220. STOP all anticoag/antiplatelet immediately. Do NOT give lytics.

← Ischemic stroke pathway
Recognition
  • ABCs · GCS · pupils · NIHSS · fingerstick glucose
  • HEAD-IC: Hx anticoag/antiplatelet, EtOH/drugs, age, DBP/SBP, intubation need (GCS ≤ 8), coags
  • ICH score: GCS, age ≥ 80, infratentorial, volume ≥ 30 mL, IVH (predicts 30-d mortality)
  • Labs: CBC, BMP, PT/INR, aPTT, type & screen, troponin, β-hCG, anti-Xa if on DOAC
  • Reverse coagulopathy before CTA when feasible (don't delay imaging though)
Management
Imaging — ICH pathway
  • Non-contrast CT head — confirms hemorrhage, location, volume (ABC/2), IVH, mass effect
  • CTA head & neck — spot sign predicts expansion; rule out AVM, aneurysm, fistula
  • CT venogram if lobar/atypical or suspected CVST (young, OCP, postpartum)
  • Repeat NCCT at 6 h or with neuro change to assess hematoma expansion (≥ 6 mL or 33%)
  • MRI/MRA later for underlying lesion (cavernoma, tumor, amyloid)
  • ABC/2 volume estimate (cm): A = largest diameter, B = perpendicular, C = slice thickness × number of slices.
BP targets
  • SBP 150–220 & no contraindication: rapid lowering to SBP 140 is safe (INTERACT-2/ATACH-2)
  • SBP > 220: aggressive IV infusion; target SBP 140–160
  • Avoid: SBP < 130 (renal injury, no benefit)
  • Goal MAP: 65–110; CPP > 60 if ICP monitor
  • First-line: drip 5 mg/hr titrate q5 min (max 15 mg/hr) or 1–2 mg/hr. Bolus: 10–20 mg IV q10 min.
Anticoag / antiplatelet reversal
  • Warfarin (any INR ≥ 1.4)
    weight + INR-based + 10 mg IV slow over 10 min. Recheck INR at 30 min & q6h.
  • Dabigatran (Pradaxa)
    Idarucizumab 5 g IV (2 × 2.5 g vials). If unavailable: 50 U/kg + activated charcoal if < 2 h. HD if refractory.
  • Factor Xa inhibitors (apixaban, rivaroxaban, edoxaban)
    Andexanet alfa (low/high dose by agent + last dose). Alternative: 50 U/kg.
  • LMWH / UFH
    1 mg per 100 U (last 2–3 h) or 1 mg per 1 mg if < 8 h (max 50 mg).
  • tPA-related ICH
    Stop infusion · cryoprecipitate 10 U IV · 1 g IV over 10 min · platelets if < 100k.
  • Antiplatelet (ASA / clopidogrel)
    Routine platelet transfusion not recommended (PATCH trial — worse outcomes). Consider only for neurosurgical intervention.
Key medication dosing (tap drug for full info)
  • 5 mg/hr IV, titrate by 2.5 mg/hr q5 min (max 15)
  • 10–20 mg IV q10 min PRN (max 300 mg)
  • () 25–50 U/kg IV based on INR
  • 10 mg IV slow over 10 min
  • 1 mg per 100 U (max 50 mg)
  • 1 g IV over 10 min (-related ICH)
  • Mannitol 1 g/kg IV bolus (herniation, ICP crisis)
  • 3% hypertonic saline 250 mL IV bolus
  • Levetiracetam 1000 mg IV (only if clinical seizure)
  • 25–50 mcg IV + drip (post-intubation sedation)
Disposition & consults
  • : cerebellar > 3 cm, brainstem compression, hydrocephalus, EVD candidate
  • : SCDs immediately; pharmacologic at 24–48 h if hematoma stable
ICH score calculator
ICH score
0 / 6
30-day mortality
0%

Hemphill et al. Stroke 2001. GCS 3–4 = 2 pts, 5–12 = 1 pt, 13–15 = 0. Age ≥ 80, vol ≥ 30 mL, infratentorial, IVH = 1 pt each. Educational aid only.

Educational aid only — verify against local ICH protocol & most recent AHA/ASA guideline.