Synopsis
Diagnose non-traumatic intracerebral haemorrhage rapidly, identify haematoma expansion and secondary causes, deliver cause-appropriate acute care, and understand the limits of blood-pressure, reversal, prognostic and surgical rules.
- Spontaneous ICH is bleeding into brain parenchyma without trauma; keep it separate from traumatic contusion, aneurysmal SAH, haemorrhagic transformation of infarction and extra-axial bleeding.
- Non-contrast CT confirms blood and defines location, volume, intraventricular extension, hydrocephalus and mass effect. Repeat CT is driven by early expansion risk and any neurological decline.
- Deep basal-ganglia, thalamic, pontine or cerebellar bleeding often reflects small-vessel arteriopathy; lobar bleeding broadens the differential to cerebral amyloid angiopathy, macrovascular lesions, tumour, venous disease and drug-associated causes.
Key red flags
Declining consciousness, worsening focal deficit, new anisocoria, repeated vomiting, posturing or abnormal respiration suggests expansion, hydrocephalus or herniation and requires immediate reassessment and repeat imaging.
Cerebellar haemorrhage with brainstem compression, obstructive hydrocephalus or neurological deterioration is a neurosurgical emergency even when supratentorial rules seem reassuring.
Intraventricular extension plus hydrocephalus contributing to impaired consciousness may require emergency external ventricular drainage; the drain treats CSF obstruction rather than the parenchymal clot itself.
Anticoagulant-associated ICH requires immediate identification of exact agent, last dose and renal function. Drug-specific reversal must follow current product status, specialist guidance and UK jurisdiction or local availability.
Young age, lobar or posterior-fossa location, absent small-vessel-disease markers, vascular imaging abnormality, cancer, pregnancy or venous thrombosis clues increase suspicion of a secondary cause.
A high ICH score must not be used alone to limit active treatment or make an early irreversible prognosis; the score is a descriptor built from historical cohorts.
Sudden hemiparesis, hemisensory loss, aphasia, neglect, ataxia, vertigo, gaze deviation or dysarthria can resemble ischaemic stroke. Headache, vomiting, seizure and reduced consciousness increase suspicion of haemorrhage but imaging is required.
Record last known well, witnessed onset, pre-hospital change, GCS and NIHSS-compatible findings. New deterioration after the first scan may represent expansion, intraventricular extension, hydrocephalus, seizure, hypoxia or systemic instability.
Reasoning priorities
Differentiate ICH from ischaemic stroke and define the anatomical threat.
Describe location, estimated volume, intraventricular extension, hydrocephalus, midline shift, basal cisterns and signs of herniation. Look for subarachnoid blood, mass or venous pattern that redirects the diagnosis.
Worked reasoning
An adult presents within hours with spontaneous parenchymal haemorrhage and no trauma.
- Activate stroke and neurocritical teams, stabilise airway and oxygenation, obtain immediate CT, record exact onset, GCS, focal deficit, baseline function, blood pressure and all antithrombotic exposure.
- Classify location, volume, ventricular extension, hydrocephalus and mass effect; send core bloods, stop antithrombotics and seek haematology input. Use four-factor PCC plus IV vitamin K for VKA-associated ICH and idarucizumab 5 g for adult dabigatran-associated life-threatening bleeding. For factor-Xa exposure, make an agent-specific specialist decision: andexanet is licensed in adults for life-threatening or uncontrolled apixaban/rivaroxaban bleeding, not edoxaban; NICE TA697 commissioning is restricted to gastrointestinal bleeding, and the April 2026 BSH position warns that thrombosis and ischaemic-stroke risk may outweigh benefit, so it is not routine class-wide ICH reversal.
- Apply the exact NICE blood-pressure rule only when its conditions fit: consider rapid lowering for acute ICH presenting within 6 hours with systolic BP 150–220 mmHg, aiming for 140 mmHg or lower without a fall greater than 60 mmHg in the first treatment hour. Separately, ESO/EANS suggests below 140 mmHg within 6 hours for adults with minor or moderate ICH under 30 mL, avoiding a fall over 70 mmHg or active reduction below 110 mmHg and using caution above 220 mmHg, in larger clots or when evacuation is planned.
- Discuss immediately with neurosurgery for posterior-fossa bleeding, hydrocephalus with impaired consciousness, herniation, progressive decline or a potentially treatable selected supratentorial lesion.
- Repeat examination and CT according to early risk and any change, then investigate the cause through vascular or MRI pathways when phenotype warrants it.