1.Immediate Assessment
Stabilize ABCs. Baseline exam (GCS, pupils, focal deficits). Anticoagulant history: agent and last dose.[+]
2.Imaging
NCCT head: location, volume (ABC/2), IVH, midline shift. CTA if vascular etiology possible (young, lobar, no HTN).[+]
3.Anticoagulation Reversal
Warfarin: 4-factor PCC 25-50 units/kg IV + Vitamin K 10 mg IV (goal INR <1.4). If PCC unavailable, FFP 10-15 mL/kg. Dabigatran: idarucizumab 5 g IV. Xa inhibitors: 4-factor PCC 50 units/kg IV. Andexanet alfa was withdrawn from the US market (commercial sales ended Dec 22, 2025). Do not wait for labs when the history is clear. (2022 AHA/ASA ICH, Class I, Level B.)[+]
4.Blood Pressure
For mild-to-moderate ICH presenting with SBP 150-220 mmHg, acute lowering to a target of SBP 140 mmHg (goal range 130-150) may be reasonable within 1 hour (Class IIb, Level B-R). Nicardipine or labetalol. Avoid lowering SBP <130 mmHg (potentially harmful, Class III); avoid rapid drop (e.g. >90 mmHg in 1 h). Evidence: INTERACT-2 and ATACH-2 did not meet their primary endpoints; 2022 AHA/ASA ICH Guidelines.[+]
5.ICP and Herniation
HOB 30°. Hyperosmolar therapy (mannitol, 3% saline). Hyperventilation as bridge only. EVD if hydrocephalus from IVH.[+]
Surgery
Most supratentorial ICH: medical. STICH II-type: consider evacuation. Cerebellar hemorrhage with neurological decline, brainstem compression, hydrocephalus, or diameter >3 cm: evacuate (Class 1, Level B-NR). EVD for hydrocephalus from IVH.[+]
6.ICU and Complications
Seizure: treat if clinical; no routine prophylaxis. DVT: SCDs; chemoprophylaxis after 24–48 h if stable. Glucose 140–180. Treat fever.[+]
Do not give tPA or antiplatelets in acute ICH. Reverse anticoagulation before any elective procedure.
References: 2022 AHA/ASA Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage. Stroke. 2022.[+]