Synopsis
Recognise spontaneous intracerebral haemorrhage, stabilise the patient, reverse relevant antithrombotic effects and coordinate blood-pressure, neurosurgical and complication management using a time-critical specialist pathway.
- Intracerebral haemorrhage commonly presents with sudden focal deficit, headache, vomiting, seizure or reduced consciousness and cannot be distinguished reliably from ischaemic stroke without urgent brain imaging.
- Obtain non-contrast CT immediately, define haematoma site and volume, intraventricular extension, hydrocephalus and mass effect, and consider CTA for an underlying vascular lesion or expansion risk.
- Record anticoagulant and antiplatelet exposure, exact last dose, blood pressure, glucose, platelets, INR, renal function and time of onset while stabilising airway, breathing and circulation.
- Reverse warfarin-related haemorrhage urgently with four-factor prothrombin complex concentrate plus intravenous vitamin K, and use anticoagulant-specific emergency pathways for dabigatran or factor Xa inhibitors.
- For eligible spontaneous intracerebral haemorrhage presenting within 6 hours with systolic pressure 150–220 mmHg and no NICE exclusion, consider controlled reduction to 140 mmHg or lower while ensuring the fall does not exceed 60 mmHg in the first hour; avoid hypotension and individualise when perfusion or raised-pressure concerns exist.
- Routine platelet transfusion for spontaneous ICH in a patient taking antiplatelets is not beneficial and may be harmful unless a specific surgical or haematological indication is established.
- Early neurosurgical discussion is essential for cerebellar haemorrhage with deterioration, brainstem compression or hydrocephalus, and for selected lobar or intraventricular cases; not every deep haemorrhage benefits from evacuation.
- Prevent aspiration, VTE, fever, glucose extremes and pressure injury on a specialist stroke or neurocritical unit, and investigate deterioration with repeat imaging rather than assuming the initial bleed is static.
Key red flags
GCS decline, unequal pupils, extensor posturing or respiratory irregularity indicates impending herniation and needs immediate airway, neurocritical and neurosurgical action.
Cerebellar blood with hydrocephalus, brainstem compression or neurological deterioration is a time-critical surgical emergency.
Recent anticoagulant exposure with ICH requires reversal to begin as soon as clinically possible; do not wait for non-essential investigations or transfer.
Marked pressure elevation with cardiac, renal or neurological target-organ injury requires monitored treatment while preserving cerebral perfusion.
Young age, lobar location, subarachnoid extension or unusual calcification should prompt urgent vascular imaging for malformation, aneurysm or venous thrombosis.
Investigation priorities
Confirm haemorrhage and define location, size, ventricular extension, hydrocephalus, oedema and mass effect.
Management branches
Urgent CT confirms spontaneous intracerebral haemorrhage.
- Stabilise airway, breathing and circulation, elevate the head appropriately, correct hypoxia and glucose emergencies and establish frequent neurological observations.
- Notify stroke or neurocritical care and neurosurgery according to location and severity, and document onset, premorbid function and escalation wishes without delaying active treatment.
- Review antithrombotic exposure and begin indicated reversal immediately while obtaining full blood count, coagulation, renal function and group-and-save samples.
- Start protocol-led blood-pressure management when eligible and obtain CTA or repeat imaging according to the clinical and anatomical risk.
The haemorrhage is stable and acute surgical or reversal decisions are complete.
- Determine likely cause from location, vascular imaging, MRI markers, blood pressure history and drug exposure and arrange any delayed angiography or tumour assessment.
- Establish sustained blood-pressure treatment, adherence support and home monitoring while addressing smoking, alcohol, stimulants and sleep apnoea where relevant.
- Review every antithrombotic indication with stroke, cardiology or haematology input and decide whether, when and what to restart based on individual risks.