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.
Key red flags
GCS decline, unequal pupils, extensor posturing or respiratory irregularity indicates impending herniation and needs immediate airway, neurocritical and neurosurgical action.
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.
The haemorrhage is stable and acute surgical or reversal decisions are complete.
Key medicines
Four-factor prothrombin complex concentrateFor warfarin-associated intracranial bleeding, give an urgent intravenous dose based on presenting INR, body weight and the specific product or local major-haemorrhage protocol.
PhytomenadioneGive intravenous vitamin K, commonly 5–10 mg under the major-haemorrhage protocol, at the same time as PCC for warfarin-associated intracerebral haemorrhage.