Intracerebral haemorrhage (ICH) management

Intracerebral haemorrhage (ICH) accounts for 11% to 22% of incident strokes and half of all stroke deaths. In general, the management of ICH is similar to that for ischaemic stroke, e.g. rapid assessment, stroke unit care, routine investigations, and prevention of complications, but there is also medical and surgical management specific to patients with ICH.

Potential medical interventions aim to reduce the growth of haematoma, or build-up of blood due to bleeding in the brain, which is strongly associated with worse patient outcomes. Reversal of coagulopathy and control of blood pressure are the main strategies currently available.

The incidence of ICH in the first year of warfarin therapy has been reported to be 1.9%. Despite the availability of reversal agents for warfarin, the risk of disability and death is higher than other causes of ICH. The incidence of ICH with direct oral anticoagulants (DOACs) is significantly lower than with warfarin. Mortality was similar to warfarin-related bleeds in the era prior to specific reversal agents for DOACs. It remains to be seen whether these reversal agents are able to reduce morbidity associated with DOAC-related ICH.

Management of blood pressure is particularly important as an elevated blood pressure is common in ICH patients and may increase haematoma expansion. However, the optimal target of blood pressure remains controversial.

The aim of surgery for ICH is to reduce the volume of haemorrhage, prevent rebleeding, and remove the mass effect so that tissue damage is reduced. However, the true effectiveness, timing and practice of operative neurosurgical interventions remain unclear.

In recent years, intraventricular thrombolysis has also been investigated for the management of intraventricular haemorrhage, which has a mortality rate of 50–80% and is traditionally managed by cerebrospinal fluid drainage.

For current research and evidence-based recommendations see our Clinical Guidelines.