Management of Spontaneous Intracerebral

Hemorrhage (ICH) / Intraparenchymal Hemorrhage (IPH)

Determine ICH Score and Max ICH Score:

Making the Diagnosis
ICH Max ICH
Emergency Department Measurement Value Score Score
• Call Stroke Level 1 for symptom onset < 24 hours Points Points
from LKW 0-6 0
• Refer to NIH Stroke Scale (document in all patients) 7-13 1
NIHSS
14-20 2
Inpatient ≥21 3
• Consult Stroke Team- Internal Stroke Code
3−4 2
• Call ERT for evaluation of patient with stroke
symptom onset < 24 hours from LKW: GCS score 5−12 1
o UH Main and East: 6-3133 13−15 0
• ERT will activate Stroke Code after initial evaluation ≤69 0 0
70-74 0 1
Initial Diagnostic Evaluation Age (years)
75-79 0 2
With the exception of Level 1 alerts, consult ≥80 1 3
Neurovascular / Neurosurgery Service when ICH Yes 1 1
Intraventricular
diagnosis is confirmed on CT.
Hemorrhage No 0 0
Primary Tests (for all patients) ICH Volume <30 0
• Non-contrast head computed tomography (CT) or (cm3) ≥30 1
magnetic resonance imaging (MRI)
• Complete blood count (CBC) Lobar ICH <30 0
• Platelet count and platelet function assay volume (cm3)* >30 1
• Blood chemistry (electrolytes, BUN, creatinine) Nonlobar ICH <10 0
• PT/aPTT/INR volume (cm )*3
≥10 1
• Troponin
Infratentorial Yes 1
• Type and cross
origin of ICH No 0
• HbA1C
• Serum alcohol level Oral Yes 1
• Liver function tests Anticoagulation No 0
• Toxicology screen Total ICH Score 0-6 0-10
• Urine drug screen *More than 1 point for the Max ICH volume score
• Electrocardiogram (ECG) can only be attained with 2 distinct ICH (1 large
• Consult Hematology for known or suspected lobar and 1 large nonlobar)
hematologic disorders o Lobar ICH defined as ICH originating at the
cortex and cortical-subcortical junction
Additional Tests (consider in special cases)
o Nonlobar ICH defined as deep (basal
• CT angiography and contrast-enhanced CT to help ganglia, thalamus, internal capsule, deep
identify patients at risk for hematoma expansion periventricular white matter), cerebellar,
• When there is clinical or radiological suspicion for and brainstem origin
underlying structural lesions, including vascular
malformation and tumors, consider the following:
Antithrombotic-Associated and Anticoagulant-
o CT angiography Associated ICH Management
o CT venography
• See Appendix B: Reversal of Coagulopathy-
o Contrast-enhanced CT
Associated Intracerebral Hemorrhage algorithm.
o Contrast-enhanced MRI
• For patients previously on antiplatelet agents, there
o MRI angiography
is no evidence that platelet transfusion improves
o MRI resonance venography
outcomes in ICH. A single dose of desmopressin
• Conventional cerebral angiogram for possible
(DDAVP) 0.4mcg/kg can be considered.
small AVM or fistulae that can be missed on CT
angiography or MRI angiography • For recommendations on anticoagulant reversal,
please refer to the OSUWMC guidelines:
o Dabigatran (Pradaxa®) Reversal Treatment
for Bleeding Events
o Rivaroxaban, Apixaban: Factor Xa Inhibitors
- Reversal Treatment for Bleeding

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 2
o Warfarin - Management of Elevated INR low-molecular-weight heparin or unfractionated
and Reversal heparin with hemiplegia or immobility after 1 to 4
o Unfractionated Heparin (UFH) and Low days.
Molecular Weight Heparin (LMWH) • In post-surgical patients, pharmacologic VTE
Reversal prophylaxis is at the discretion of surgical team
• Consider placement of a temporary vena cava filter
Thrombolytic Reversal
for patients who develop an acute proximal venous
• For recommendations on symptomatic
thrombosis, particularly those with clinical or
hemorrhagic conversion after alteplase (tPA)
subclinical PE
administration, please refer to Appendix B.
• When deciding whether to add long-term anti-
Initial Medical Care thrombotic therapy several weeks or more after
placement of a temporary vena cava filter, consider:
• Admit to ICU or PCU for monitoring and o The cause of the hemorrhage
management o Associated conditions with increased
• Perform dysphagia screen prior to any oral intake thrombotic risk (e.g., atrial fibrillation)
• Manage clinical seizures with appropriate o Patient’s health and mobility
antiepileptic therapy General Medical Care
o Prophylactic anticonvulsant medication
should not be used • Temperature should be kept < 99.1°F (37.3°C)
• Normotonic fluids are strongly recommended • Glucose should be monitored (normoglycemia is
o Avoid hypotonic fluids to prevent recommended)
exacerbating brain edema
• Manage elevated HgbA1C and/or fasting lipids
• Treat sources of fever and administer
• Correct any major nutritional or hydration
acetaminophen to lower temperature in febrile
problems
patients
• Provide stroke education
• Treat hypoglycemia / hyperglycemia
• Provide tobacco cessation information
• Arterial line placement for continuous BP monitoring
• Consult the following as indicated:
• Continuous EEG:
o Physical Medicine and Rehabilitation
o Depressed clinical exam inconsistent with
the neurological deficits of ICH o PT
o OT
Hypertension Management o Speech Language Pathology
• High systolic BP is associated with greater • Withdraw care recommendations should be
hematoma expansion, neurological deterioration, cautious and occur after aggressive care for
dependency, and death following ICH patients without preexisting DNR orders
• Early and rapid BP lowering improves patients’ o Consider Palliative Care consult
chances of achieving better functional recovery • In patient with atrial fibrillation restarting
• Rapid lowering of SBP to 130 - 150 mmHg, anticoagulation treatment should be considered
preferably targeting a SBP of 140 mmHg 7-8 weeks after spontaneous ICH to optimize the
o Rapid aggressive reduction of BP with benefit from treatment and minimize the risk.
IVP or continuous IV infusion with
frequent BP monitoring every 5 min. Surgical Care
 hydralazine, labetalol,
• Ventricular drainage as treatment for
nicardipine, esmolol (avoid
hydrocephalus is reasonable in patients with
nitroprusside) decreased level of consciousness
 Clevidipine can be considered
• For patients with cerebellar hemorrhage
in patients who have failed
> 3 cm, who are deteriorating neurologically or
nicardipine therapy
who have brain stem compression and/or
Increased Intracranial Pressure (ICP) hydrocephalus from ventricular obstruction,
Management (See Appendix A: ICP algorithm ) surgical removal of the hemorrhage should occur
• Consider inpatients with GCS score ≤ 8, clinical as soon as possible
evidence of impending transtentorial herniation, • Consider injection of alteplase (TPA) into
significant IVH, or hydrocephalus hematoma, minimally invasive clot evacuation,
• ICP monitoring will be initiated after evaluation by decompressive craniectomy, or evacuation of
Neurosurgery supratentorial ICH by standard craniotomy for
Pharmacological and Mechanical VTE Prophylaxis select patients
(See Deep Venous Thrombosis (DVT): Prevention guideline) • The patient should be assessed by the
Place sequential compression devices (SCDs) barring any neurosurgeon both before and after surgery
contraindications.
• After documentation of cessation of bleeding in non-
surgical patients, consider low-dose subcutaneous

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University Technology Commercialization Office
 3
Prevention of Recurrent ICH Associated Tools

• Address ongoing blood pressure Order sets

needs to maintain BP <130/80 mmHg • Stroke Alert [2993]
• Recommend discontinuation of tobacco use, • Hemorrhagic Stroke Confirmed [2972]
heavy alcohol use, and substance abuse • Admission Spontaneous Intracerebral
• For some patients, avoid long-term Hemorrhage (ICH / IPH) [2190]
anticoagulation as treatment for nonvalvular atrial
fibrillation after spontaneous lobar ICH due to the Quality Measures
relatively high risk of recurrence
• Anticoagulation after nonlobar ICH and • Venous thromboembolism (VTE) prophylaxis
antiplatelet therapy after all ICH might be • Dysphagia screening
considered, particularly when there are definite • Stroke education
indications for these agents • Assessed for rehabilitation
Discharge Planning • Severity measurement performed for SAH and
ICH patients (overall rate)
• Involve patient’s family/caregiver in assessment of • Procoagulant reversal agent initiation for
post discharge needs, decision making and intracerebral hemorrhage (ICH)
treatment planning. References
o Perform full NIH Scale and Modified
Rankins Scale at discharge as well as at • Anderson CS, et al. (2013). Rapid Blood-Pressure
90-days post-discharge Lowering in Patients with Acute Intracerebral
o Follow-up outpatient appointment with the Hemorrhage. The New England Journal of
Neurovascular Stoke Team scheduled Medicine, 368:2355-2365.
prior to discharge
• Hemphill JC III, et al. (2001). The ICH Score: A
Multidisciplinary Focus Simple, Reliable Grading Scale for Intracerebral
• Provide education for patient’s familyand/or Hemorrhage. Stroke, 32(4): 891-897.
caregivers on: • Honner SK, et al. (2011). Emergency department
o Stroke: control of blood pressure in intracerebral
 Activation of EMS system hemorrhage. The Journal of Emergency
 Pathology Medicine, 41(4):355-61.
 Prevention • James PA, et al. (2014). 2014 Evidence-Based
 Signs/ symptoms Guideline for the Management of High Blood
 Actions to take Pressure in Adults: Report from the Panel
o Follow-up appointments/therapy Members Appointed to the Eighth Joint National
o Treatment plan Committee (JNC 8). Journal of the American
o Community resources and how to access Medical Association, 311(5): 507-520.
those resources • Morgenstern LB, et al. (2010). Guidelines for the
Management of Spontaneous Intracerebral
Rehabilitation Services
Hemorrhage: A Guideline for Healthcare
• Encourage patient’s family/caregiver to participate Professionals from the American Heart
in the rehabilitation sessions and to be trained to
Association/American Stroke Association.
assist the patient with functional activities
Stroke, 41: 2108-2129.
• If the patient is aphasic, staff should assist the
• Sakamoto Y, et al. (2013). Systolic Blood
patient and family in establishing a communication
Pressure after Intravenous Antihypertensive
pattern before discharge
Treatment and Clinical Outcomes in Hyperacute
Case Manager Intracerebral Hemorrhage: The Stroke Acute
• Arrange family and team meeting to discuss: Management with Urgent Risk-Factor Assessment
o Patient progress and Improvement-Intracerebral Hemorrhage
o Rehabilitation goals Study. Stroke, 44(7):1846-51.
o Discharge needs or issues • Tommasino C. (2002). Fluids and the
o Explanation of next level of care Neurosurgical Patient. Anesthesiology Clinics of
o Providing care and support associated North America, 20(2):329–346.
with these deficits • Hemphill JC 3rd, et al. (2015). Guidelines for the
o Means of coping with stress associated Management of Spontaneous Intracerebral
with these impairments Hemorrhage a Guideline for Healthcare
• Consider availability of support services and Professionals From the American Heart
desires of the patient’s family/caregiver Association/American Stroke Association.
• Provide information about discharge plans and Stroke, doi: 10.1161/STR.0000000000000069.
post-discharge management to primary care
physicians and community services

Copyright © 2008. The Ohio State University. All rights reserved. No part of this document may be reproduced, displayed, modified, or distributed in any form without a written agreement with
the Ohio State University Technology Commercialization Office
 4
• Baharoglu, M Irem et al. Platelet transfusion Guideline Approved
versus standard care after acute stroke due to
spontaneous cerebral haemorrhage associated January 31, 2018 Eighth Edition.
with antiplatelet therapy (PATCH): a
randomisedopen-label, phase 3 trial. The Lancet ,
Volume 387 , Issue 10038 , 2605 – 2613
Disclaimer: Clinical practice guidelines and algorithms at The
• Frontera JA, Lewin JJ, Rabinstein AA, et al. Ohio State University Wexner Medical Center (OSUWMC) are
Guideline for Reversal of Antithrombotics in standards that are intended to provide general guidance to
Intracranial Hemorrhage: Executive Summary. A clinicians. Patient choice and clinician judgment must remain
Statement for Healthcare Professionals From the central to the selection of diagnostic tests and therapy.
Neurocritical Care Society and the Society of Critical OSUWMC’s guidelines and algorithms are reviewed periodically
Care Medicine. Crit Care Med. 2016;44(12):2251- for consistency with new evidence; however, new developments
2257. may not be represented.
• Nyquist P, Jichici D, Bautista C, et al. Prophylaxis of
Venous Thrombosis in Neurocritical Care Patients: An
Executive Summary of Evidence- Based Guidelines:
A Statement for Healthcare Professionals From the
Neurocritical Care Society and Society of Critical
Care Medicine. Crit Care Med. 2017;45(3):476-479.
• Hanley DF, Lane K, Mcbee N, et al. Thrombolytic
removal of intraventricular haemorrhage in treatment
of severe stroke: results of the randomised,
multicentre, multiregion, placebo- controlled CLEAR
III trial. Lancet. 2017;389(10069):603-611.
• Anderson CS, Heeley E, Huang Y, et al. Rapid
blood-pressure lowering in patients with acute
intracerebral hemorrhage. N Engl J Med.
2013;368(25):2355-65.
• Qureshi AI, Palesch YY, Barsan WG, et al.
Intensive Blood-Pressure Lowering in Patients with
Acute Cerebral Hemorrhage. N Engl J Med. 2016;
• Nielsen PB, Johnsen SP. Letter by Nielsen and
Johnsen Regarding Article, "Optimal Timing of
Anticoagulant Treatment After Intracerebral
Hemorrhage in Patients With Atrial Fibrillation".
Stroke. 2017;48(4):e115.
• Zemrak WR, Smith KE, Rolfe SS, et al. Low- dose
Prothrombin Complex Concentrate for Warfarin-
Associated Intracranial Hemorrhage with INR
Less Than 2.0. Neurocrit Care. 2017;Sembill, J.
A., et al. (2017). Severity assessment in
maximally treated ICH patients. Neurology,
89(5), 423-431.
doi:10.1212/wnl.0000000000004174
Guideline Authors
• Ciaran Powers, MD, PhD.
• Michel Torbey, MD
• Noah Grose, RN, BSN, MSN, ACNP-BC
• Peg Baylin, PharmD
• Keaton Smetana, PharmD, BCCCP
• Vivien Lee, MD
• Kelsey Kauffman, PharmD

Copyright © 2008. The Ohio State University. All rights reserved. No part of this document may be reproduced, displayed, modified, or distributed in any form without a written agreement with
the Ohio State University Technology Commercialization Office
 Appendix A: Increased Intracranial Pressure (ICP) Management Algorithm

Criteria for ICP Management

If ICP is > 22 mmHg for more than 5 minutes or ICP is > 25 mmHg

Initial Interventions
 Troubleshoot ICP to ensure accuracy of monitored data
 Call Neurosurgery House Officer or neurocritical care team
 Elevate head of bed 30°, midline position
 Assess level of sedation and pain
 Check temperature (treat if > 99°F, cooling blanket)
 Arterial blood gases (ABG)

Reassessment
 Monitor ICP
 Neuro exam

ICP normal?
Targets: Neuro exam
ICP < 22 mmHg YES Observe YES Observe
normal?
CPP > 60 mmHg
(Formula: CPP = MAP - ICP)*

NO NO

Stepwise Treatment Consider other causes, such as:

1. Stat head CT  Hypercarbia
2. Cerebrospinal fluid: Drain if appropriate. Consult  Hypoxia
Neurosurgery if considering ventriculostomy or lumbar  Hyperthermia
drain, if not already in place.  Hypoglycemia
3. Hyperosmolar therapy:  Inadequate sedation/ analgesia
 Suctioning
Central   Mass lesion
NO YES  Cerebral edema
Access
 Technical problem with ICP monitor

 Mannitol 0.5‐1.5g/kg 23.4% 30mL 
or Administer over 5‐10 
3% NaCl 4mL/kg minutes 

● Mannitol: consider holding if osmolar gap >/= 20 mOsm/kg

● Hypertonic saline: 3% maximum 500 mL, consider holding for
osmol greater than 320 mOsm/kg or serum Na greater than
160 (target serum osmol 300-320 mOsm/kg and serum Na
145-155)
4. Sedation: propofol, bolus dose 0.5-1 mg/kg can be considered,
continuous infusion max rate of 80 mcg/kg/min, or possibly
* Key: CPP = Cerebral Perfusion Pressure; MAP = Mean
induce pentobarbital coma, loading dose 5-15 mg/kg, max
Arterial Pressure
administration rate of 50 mg/min, then 1-5 mg/kg/hr.
5. Hyperventilation: PaCO2, 30-35 mmHg, use for no Notes: (1) ICP and CPP targets can be adjusted, based on
longer than 30 minutes. physician judgment. (2) Use of vasopressors to maintain
6. Surgical decompression (if surgical candidate). CPP greater than 70 is discouraged in patients with
traumatic brain injury.

References: (1) Carney N, Totten AM, O'reilly C, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition.
Neurosurgery. 2017;80(1):6-15. (2) Dixit D, Thomas Z. Letter by Dixit and Thomas Regarding Article, "Guidelines for the Management of
Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke
Association". Stroke. 2015;46(11):e236. (3) Cadena R, Shoykhet M, Ratcliff JJ. Emergency Neurological Life Support: Intracranial
Hypertension and Herniation. Neurocrit Care. 2017;
Copyright © 2008. The Ohio State University. All rights reserved. No part of this document may be reproduced, displayed, modified, or distributed in any form without a written agreement with the Ohio State
University Technology Commercialization Office
 Appendix B: Reversal of Coagulopathy-Associated Intracerebral Hemorrhage (ICH) Algorithm
Notify Attending

Patient on rivaroxaban
Patient received alteplase (tPA) Patient on unfractionated heparin (UFH) or Patient on warfarin Patient on dabigratran
(Xarelto®) or apixaban
within the last 24 hours low molecular weight heparin (LMWH) (Coumadin®) (Pradaxa®)
(Eliquis®)

Discontinue UFH or LMWH. See

Discontinue warfarin therapy. See See Dabigatran (Pradaxa) See Factor Xa Inhibitors
Discontinue Unfractionated Heparin (UFH) and Low
Warfarin: Management of Elevated INR and Reversal Treatment for Reversal Treatment for
alteplase Molecular Weight Heparin (LMWH) Reversal
Reversal guideline Bleeding guideline Bleeding guideline
guideline.

Goal: Correction of INR > 1.4

For symptomatic hemorrhagic conversion a

reversal agent may be considered if alteplase was  Give Phytonadione (Vitamin K) 10 mg by slow IV INFUSION over 15 minutes Risk of Thromboembolism from
received within 24 hours (Do NOT give subcutaneously or intramuscular due to erratic absorption.) PCC
 Cryoprecipitate to target a fibrinogen level of > AND EITHER
150 mg/dL with an initial dose of 10 units * PCC (Prothrombin Complex
 Single dose of tranexamic acid 1,000 mg  Four-factor Prothrombin Complex Concentrate (PCC) [Kcentra®]* See Concentrate) is a factor IX
(10 – 15 mg/kg) IV or amniocaproic acid 4-5g Contraindications and Precautions.** RISK (thromboembolism) vs. BENEFIT concentrate that also contains factors
IV if cryoprecipitate is contraindicated or not must be considered. II, VII, and X. Dose is based on
available in a timely manner factor IX units. It is ordered from and
Baseline INR > 4
< 4 EVALUATE supplied by pharmacy.
*In small, asymptomatic hemorrhagic conversion, RISKS
conservative medical management may be Kcentra ® Dose 25 units/kg 35 units/kg ** PCC should only be administered
considered after weighing the risks and benefits of to patients when the beneficial effects
reversal agents of use outweigh the serious risk of
**The risk of thrombosis, especially in patients who OR potential hypercoagulation. The use
just experienced an ischemic stroke, should be  Fresh Frozen Plasma 10-15 mL/kg if INR <2 and no emergent intervention of factor products has been
heavily weighed. planned associated with thromboembolic
complications including thrombosis
and disseminated intravascular
After Reversal Agent Administered
coagulation. Clinical surveillance for
early signs of consumptive
 Recheck INR 15-30 minutes after administration and every 6 hours for the first
coagulopathy should be initiated with
24 hours
appropriate biological testing when
 If repeat INR ≥ 1.4, consider additional FFP for persistent bleeding or re-dosing
administering PCC.
Kcentra ® with reduced dose [Do not exceed a maximum cumulative dose of
5000 units or 50units/kg in a 24-hour period
 Phytonadione may be repeated every 12 hours, although consider the need for
re-anticoagulation

INR remains > 1.4

 Consider giving FFP 10-15 mL/kg rounded to the nearest unit size  Consider giving Recombinant factor VII 1 mg IVP over 2-5
(Volume for each unit is 250-275 mL) minutes.
 Check INR immediately following FFP with recheck in 6-24 hours OR  Recheck INR after 15-30 minutes
 If INR remains elevated at recheck, consider more FFP  If INR remains elevated, repeat dose
References:
(1) Morgenstern LB, Hemphill JC III, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010;41:2108 –2129.
(2) Kcentra [package insert]. Kankakee, IL: CSL Behring GmbH,  August 2017
(3) Zemrak WR, Smith KE, Rolfe SS, et al. Low‐dose Prothrombin Complex Concentrate for Warfarin‐Associated Intracranial Hemorrhage with INR Less Than 2.0. Neurocrit Care. 2017;
(4) Frontera JA, Lewin JJ, Rabinstein AA, et al. Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage: Executive Summary. A Statement for Healthcare Professionals From the Neurocritical Care Society and the Society of Critical Care Medicine. Crit
Care Med. 2016;44(12):2251‐2257.
Copyright © 2008. The Ohio State University. All rights reserved. No part of this document may be reproduced, displayed, modified, or distributed in any form without a written agreement with the Ohio State University Technology Commercialization Office