Hemorrhagic Stroke Management - Current Guidelines

PART 1: Spontaneous Intracerebral Hemorrhage (ICH)

Diagnosis & Imaging

• Noncontrast CT is the first-line imaging: ICH appears as a round/oval hyperdense lesion (40-60 HU acutely, rising to 80-100 HU within days)
• CT angiography "spot sign" (focal contrast extravasation within the hematoma) predicts hematoma expansion, increased mortality, and poor functional outcome
• Check platelet count, PT/PTT/INR, basic chemistry panel on all patients
• MRA/CTA/DSA indicated when cause is uncertain, especially in young or non-hypertensive patients

ICH Score (Prognostication)

1. Initial Stabilization

• ABCs first: assess airway/breathing; intubate for GCS ≤ 8, large hematoma, or intraventricular extension
• Admit to a specialized stroke unit / neurological ICU with multidisciplinary team (Class I)
• Transfer to neurosurgical center if hydrocephalus is present (Class I)

2. Blood Pressure Management

• Initiate treatment within 2 hours of symptom onset, achieve target within 6 hours
• Use smooth, sustained IV antihypertensives - nicardipine (preferred) or labetalol infusion; avoid abrupt BP fluctuation
• Avoid SBP < 130 mmHg (ATACH-2 trial showed no benefit of ultra-intensive lowering and potential harm)
• Maintain CPP > 60-70 mmHg in large hematomas

3. Coagulopathy Reversal

• Fuster and Hurst's The Heart, 15th Edition; EMOttawa 2022 AHA/ASA Summary

4. Glucose & Temperature Management

• Glucose target (no diabetes): 6.1-7.8 mmol/L (110-140 mg/dL); avoid both hyper- and hypoglycemia
• Fever (>37.5°C): treat aggressively with antipyretics; fever increases metabolic demand and secondary brain injury

5. Seizure Management

• Routine prophylactic antiseizure medication (ASM) is NOT recommended - even in lobar hematomas (AHA/ASA 2022, Class III; confirmed by 2025 ESO guidelines)
• Treat clinical seizures with levetiracetam or fosphenytoin
• Continuous EEG (cEEG) for ≥ 24 hours is reasonable for: unexplained depressed consciousness, fluctuating mental status, clinical events suspicious for seizures, or concern for non-convulsive status epilepticus (Class IIa)

6. ICP Management

• Elevate head of bed 30 degrees
• EVD placement for hydrocephalus (Class I)
• ICP monitoring: consider if GCS ≤ 8 with extensive hematoma or intraventricular bleeding (Class IIb)
  • Target ICP < 20-22 mmHg; CPP 50-70 mmHg
• Hyperosmolar therapy (bolus only, not prophylactic):
  • Mannitol 0.25-1 g/kg IV bolus
  • 3% NaCl 100-250 mL (preferred in hypovolemic patients)

7. VTE Prevention

• Intermittent pneumatic compression (IPC): start on day of diagnosis (Class I)
• Pharmacological prophylaxis (UFH or enoxaparin 40 mg SC daily): may initiate 24-48 hours after onset when follow-up imaging confirms hematoma stability (no expansion >33% or >6 mL) - Class IIb

8. Surgical Treatment

• Cerebellar hemorrhage > 3 cm with neurological deterioration or brainstem compression (Class I)
• Hydrocephalus from intraventricular hemorrhage - EVD placement
• Hematoma evacuation for accessible lobar clots (selected cases)

PART 2: Aneurysmal Subarachnoid Hemorrhage (aSAH)

Initial Steps

1. Emergency CT head - if negative and SAH suspected, perform lumbar puncture (xanthochromia)
2. CTA or DSA to identify the aneurysm
3. Transfer to high-volume center (>35 aSAH cases/year) with experienced cerebrovascular surgeons, endovascular specialists, and neurointensive care (evidence: 9-16% reduction in in-hospital death at high-volume centers)

Preventing Rebleeding

• Control SBP < 160 mmHg with titratable IV antihypertensives (nicardipine preferred over labetalol/nitroprusside for smoother control)
• Treat pain and anxiety: acetaminophen first-line; NSAIDs avoided (bleeding risk); opioids if severe pain
• Antifibrinolytics (tranexamic acid or aminocaproic acid): reasonable for short-term (<72 hours) use if there is an unavoidable delay in aneurysm treatment, high rebleeding risk, and no contraindications
  • Aminocaproic acid: 4 g IV bolus then 1 g/hr infusion
  • Caution: increases thromboembolic complications with prolonged use

Aneurysm Obliteration

• Early treatment (within 24-72 hours) is strongly recommended to eliminate rebleeding risk
• Endovascular coiling vs. neurosurgical clipping should be decided by multidisciplinary team based on: aneurysm location/size/morphology, patient clinical grade, and institutional expertise
• Coiling generally preferred for posterior circulation aneurysms and older/poor-grade patients; clipping preferred for middle cerebral artery aneurysms and younger patients with accessible lesions

Managing Delayed Cerebral Ischemia (DCI) / Vasospasm

• Oral nimodipine 60 mg every 4 hours for 21 days - the only proven intervention to reduce DCI and improve neurological outcome (Class I). If SBP <140, reduce dose to 30 mg. Consistent administration is critical - disruption is associated with significantly higher DCI rates.

• Transcranial Doppler (TCD) daily
• CT angiography
• Clinical neurological exam

• Hemodynamic augmentation (induced hypertension, euvolemia): first-line
• Intra-arterial vasodilators (nimodipine, verapamil) via catheter-directed infusion for refractory vasospasm
• Balloon angioplasty for severe proximal vasospasm unresponsive to pharmacotherapy

Other SAH Complications

Summary Algorithm

Hemorrhagic Stroke
    |
    ├── ICH (non-traumatic, no AVM/aneurysm)
    │       ├── Airway/BP control (target SBP <140, smooth/sustained)
    │       ├── Reverse coagulopathy (PCC/idarucizumab/andexanet)
    │       ├── ICP management (EVD, osmotherapy)
    │       ├── No routine seizure prophylaxis; EEG monitoring if indicated
    │       ├── IPC day 1; LMWH at 24-48h if stable
    │       └── Surgery: cerebellar ICH >3cm, hydrocephalus
    |
    └── aSAH (aneurysmal)
            ├── Transfer to high-volume center
            ├── Control SBP <160 (pre-treatment)
            ├── Antifibrinolytics if delayed treatment
            ├── Coiling vs. clipping (multidisciplinary decision)
            ├── Nimodipine 60mg q4h x 21 days (mandatory)
            └── Monitor/treat vasospasm (TCD, hemodynamic augmentation, IA vasodilators)

• 2022 AHA/ASA Spontaneous ICH Guideline - Greenberg SM et al., Stroke 53:e282-e361
• 2023 AHA/ASA Aneurysmal SAH Guideline - Hoh BL et al., Stroke 54:e314-e370
• 2025 ESO Guidelines for Spontaneous ICH (updates seizure prophylaxis recommendations)
• CAA-specific ICH management: 2025 International CAA Association / WSO Statement (PMID 40721902)

Pediatric note: A 2026 consensus statement (PMID 41467366) from the International Pediatric Stroke Organization covers pediatric ICH management separately - adult guidelines should NOT be directly applied to children.