Guideline on the Diagnosis and Treatment of Spontaneous Intracerebral Hemorrhage

Rapid neuroimaging with computed tomography or MRI is recommended to distinguish ischemic stroke from ICH.

Hemostasis and Coagulopathy, Antiplatelet Agents, and Deep-Vein Thrombosis Prophylaxis

• Patients with a severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets, respectively.

• Patients with ICH whose international normalized ratio (INR) is elevated because of vitamin K antagonists (VKAs) should have their VKA withheld, receive therapy to replace vitamin K–dependent factors and correct the INR, and receive intravenous vitamin K.

• Patients with ICH should have intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission.

Blood Pressure

• For patients with ICH presenting with systolic blood pressure (SBP) between 150 and 220 mm Hg and without contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg is safe and can be effective for improving functional outcome.

General Monitoring and Nursing Care

• Initial monitoring and management of patients with ICH should take place in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise.

Glucose Management

• Glucose should be monitored. Both hyperglycemia and hypoglycemia should be avoided.

Seizures and Antiseizure Drugs

• Clinical seizures should be treated with antiseizure drugs.

•  Patients with a change in mental status who are found to have electrographic seizures on electroencephalography should be treated with antiseizure drugs.

Management of Medical Complications

• A formal screening procedure for dysphagia should be performed in all patients before the initiation of oral intake to reduce the risk for pneumonia.

Surgical Treatment of ICH 

Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brain stem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible.  

Prevention of Recurrent ICH

• BP should be controlled in all patients with ICH. Measures to control BP should begin immediately after ICH onset.

Rehabilitation and Recovery

• Given the potentially serious nature and complex pattern of evolving disability and the increasing evidence for efficacy, it is recommended that all patients with ICH have access to multidisciplinary rehabilitation.