Intracerebral Hemorrhage

VERSION: 1.0 CREATED: January 27, 2026 STATUS: Approved

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DIAGNOSIS: Intracerebral Hemorrhage (ICH)

ICD-10: I61.9 (Nontraumatic intracerebral hemorrhage, unspecified), I61.0 (ICH in hemisphere, subcortical), I61.1 (ICH in hemisphere, cortical), I61.2 (ICH in hemisphere, unspecified), I61.3 (ICH in brain stem), I61.4 (ICH in cerebellum), I61.5 (ICH, intraventricular), I61.6 (ICH, multiple localized), I62.9 (Nontraumatic intracranial hemorrhage, unspecified)

CPT CODES: 85025 (CBC with differential), 85610 (PT/INR), 85730 (aPTT), 85384 (Fibrinogen), 80053 (CMP (BMP + LFTs)), 82947 (Blood glucose), 86900 (Type and screen / crossmatch), 84484 (Troponin), 80320 (Blood alcohol level), 80307 (Urine drug screen), 84703 (Pregnancy test (β-hCG)), 80061 (Lipid panel), 83036 (HbA1c), 84443 (TSH), 85652 (ESR), 85379 (D-dimer), 83930 (Serum osmolality), 86235 (ANA), 70450 (CT head without contrast), 70496 (CT angiography (CTA) head), 93000 (ECG (12-lead)), 70553 (MRI brain with and without contrast), 36224 (Conventional cerebral angiography (DSA)), 93306 (Echocardiogram), 95700 (Continuous EEG (cEEG)), 71046 (Chest X-ray), 96365 (Blood pressure reduction: Nicardipine IV), 96374 (Blood pressure reduction: Labetalol IV)

SYNONYMS: Intracerebral hemorrhage, ICH, hemorrhagic stroke, brain bleed, cerebral hemorrhage, intraparenchymal hemorrhage, hypertensive hemorrhage, spontaneous ICH, bleeding in the brain, intracerebral bleed, cerebral bleed, hemorrhagic CVA

SCOPE: Spontaneous (non-traumatic) intracerebral hemorrhage in adults. Covers acute BP management, anticoagulant reversal, ICH score and prognosis, ICP management, surgical indications, etiology workup, and secondary prevention. Excludes traumatic ICH, subarachnoid hemorrhage (separate template), hemorrhagic transformation of ischemic stroke, and subdural/epidural hematomas.

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PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

═══════════════════════════════════════════════════════════════ SECTION A: ACTION ITEMS ═══════════════════════════════════════════════════════════════

1. LABORATORY WORKUP

1A. Essential/Core Labs

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
CBC with differential (CPT 85025)	STAT	STAT	-	STAT	Baseline; thrombocytopenia as cause or complication; transfusion needs	Platelets >100,000 (>50,000 minimum for hemostasis)
PT/INR (CPT 85610)	STAT	STAT	-	STAT	Warfarin-related ICH requires emergent reversal; coagulopathy assessment	INR <1.4 target (if elevated: REVERSE IMMEDIATELY)
aPTT (CPT 85730)	STAT	STAT	-	STAT	Heparin-related ICH; coagulopathy	Normal
Fibrinogen (CPT 85384)	STAT	STAT	-	STAT	DIC; consumptive coagulopathy; tPA-related hemorrhage	>150 mg/dL (if <150: give cryoprecipitate)
CMP (BMP + LFTs) (CPT 80053)	STAT	STAT	-	STAT	Electrolytes; renal function for contrast/medication; hepatic function for coagulopathy	Normal
Blood glucose (CPT 82947)	STAT	STAT	-	STAT	Hyperglycemia worsens ICH outcomes; hypoglycemia mimics stroke	140-180 mg/dL target
Type and screen / crossmatch (CPT 86900)	STAT	STAT	-	STAT	Potential need for blood products, surgery, reversal agents	On file; crossmatch if OR likely
Troponin (CPT 84484)	STAT	STAT	-	STAT	Neurogenic cardiac injury (stress cardiomyopathy); concurrent ACS	Normal
Blood alcohol level (CPT 80320)	STAT	-	-	STAT	Coagulopathy; exam reliability; alcoholism is ICH risk factor	Document result
Urine drug screen (CPT 80307)	STAT	-	-	STAT	Cocaine/amphetamine-associated ICH (sympathomimetic surge)	Negative
Pregnancy test (β-hCG) (CPT 84703)	STAT	STAT	-	STAT	Affects management (eclampsia differential; imaging)	Document result
Thrombin time (TT) and/or ecarin clotting time (ECT)	STAT	STAT	-	STAT	Dabigatran (direct thrombin inhibitor) detection; if patient on DOACs	Normal (prolonged = dabigatran present)
Anti-Xa level (calibrated for specific DOAC)	STAT	STAT	-	STAT	Rivaroxaban/apixaban/edoxaban detection; guides reversal need	Negative/undetectable (elevated = DOAC present and active)

1B. Extended Workup (Second-line)

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Lipid panel (CPT 80061)	-	ROUTINE	ROUTINE	-	Cardiovascular risk; statin decision (controversial post-ICH)	Document baseline
HbA1c (CPT 83036)	-	ROUTINE	ROUTINE	-	Diabetes management	<7.0%
TSH (CPT 84443)	-	ROUTINE	-	-	Thyroid dysfunction	Normal
ESR (CPT 85652) / CRP (CPT 86140)	-	ROUTINE	ROUTINE	-	Vasculitis screen; inflammatory etiology	Normal
D-dimer (CPT 85379)	URGENT	ROUTINE	-	URGENT	DIC; venous thromboembolism	Normal
Serum osmolality (CPT 83930)	-	ROUTINE	-	ROUTINE	Monitor during osmotherapy (mannitol/hypertonic saline)	280-320 mOsm/kg; hold osmotherapy if >320

1C. Rare/Specialized (Refractory or Atypical)

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Hypercoagulable panel	-	EXT	EXT	-	Young patient ICH without clear etiology; cerebral venous thrombosis with secondary hemorrhage	Normal
ANA (CPT 86235), ANCA	-	EXT	EXT	-	CNS vasculitis-related hemorrhage	Negative
Toxicology (expanded)	-	EXT	-	EXT	Sympathomimetic drug use; synthetic drug-associated hemorrhage	Negative
Amyloid-beta PET	-	-	EXT	-	Cerebral amyloid angiopathy (CAA) confirmation; research context	Positive amyloid deposition in lobar distribution
APOE genotype	-	-	EXT	-	CAA risk stratification; APOE ε2/ε4 associated with ICH	Document alleles

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2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
CT head without contrast (CPT 70450)	STAT	STAT	-	STAT	Door-to-CT <25 minutes; determines ICH diagnosis, location, volume, IVH, hydrocephalus, midline shift	Hemorrhage location (deep: basal ganglia/thalamus = hypertensive; lobar: CAA, tumor, AVM), volume (ABC/2 method), intraventricular hemorrhage (IVH), hydrocephalus, midline shift >5mm	Pregnancy (benefit outweighs risk)
CT angiography (CTA) head (CPT 70496)	STAT	STAT	-	STAT	With initial CT; identify "spot sign" (active contrast extravasation = hematoma expansion risk), underlying vascular malformation (AVM, aneurysm)	Spot sign (30-50% risk of expansion); AVM; aneurysm; dural AV fistula; Moyamoya	Contrast allergy; renal impairment (benefit outweighs risk in emergency)
ECG (12-lead) (CPT 93000)	STAT	STAT	-	STAT	Baseline; neurogenic cardiac injury; arrhythmia; QTc prolongation risk	Normal; ST changes may be neurogenic	None
Repeat CT head (non-contrast)	-	STAT	-	STAT	At 6h and 24h OR any neurologic decline; assess for hematoma expansion (>33% or >6mL increase from baseline = significant expansion)	Stable hematoma size; no new hemorrhage; no hydrocephalus progression	Same as initial

2B. Extended

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI brain with and without contrast (CPT 70553) (include GRE/SWI sequences)	-	URGENT	ROUTINE	URGENT	Within 24-72h when stable; or urgently if underlying mass/AVM suspected	Underlying tumor; cavernous malformation; microbleeds (CAA pattern: lobar; hypertensive: deep). SWI shows microhemorrhages	Pacemaker; hemodynamic instability; MRI-incompatible monitoring
MR venography (MRV)	-	ROUTINE	-	ROUTINE	If cerebral venous thrombosis (CVT) suspected as cause of hemorrhagic venous infarct	Venous sinus thrombosis	Same as MRI
Conventional cerebral angiography (DSA) (CPT 36224)	-	URGENT	EXT	URGENT	Young patient (<50) with lobar ICH and no clear etiology; suspected AVM/aneurysm where CTA inconclusive; negative initial CTA but high suspicion	AVM; aneurysm; dural AV fistula; Moyamoya; vasculitis	Contrast allergy; renal impairment; coagulopathy
Delayed DSA (if initial negative)	-	-	ROUTINE	-	Repeat at 3-6 months; small AVM may be compressed by acute hematoma and missed initially	Unmasked AVM/aneurysm	Same as initial DSA
Echocardiogram (CPT 93306)	-	ROUTINE	-	ROUTINE	Neurogenic cardiac injury; baseline cardiac function; endocarditis if mycotic aneurysm suspected	LV dysfunction; stress cardiomyopathy	None significant
Continuous EEG (cEEG) (CPT 95700)	-	URGENT	-	STAT	If altered consciousness disproportionate to hemorrhage size; suspected seizures	Non-convulsive seizures; NCSE (seen in 20-30% of ICH patients)	None
Chest X-ray (CPT 71046)	URGENT	ROUTINE	-	URGENT	Aspiration; pulmonary edema (neurogenic); baseline for ventilator	Normal	None

2C. Rare/Specialized

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
Brain biopsy	-	-	EXT	-	If underlying tumor, vasculitis, or amyloid angiopathy suspected and non-invasive workup inconclusive	Tumor; vasculitis; amyloid	Surgical risk
Amyloid PET scan	-	-	EXT	-	CAA diagnosis in lobar ICH with microbleeds	Amyloid deposition	Research/limited availability

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3. TREATMENT

⚠️ CRITICAL PRIORITIES IN ACUTE ICH (First 60 Minutes)

1. ABCs — airway, breathing, circulation
2. Blood pressure reduction — target SBP <140 mmHg within 1 hour (INTERACT2, ATACH-2)
3. Anticoagulant reversal — IMMEDIATELY if on anticoagulation
4. Repeat CT — assess for expansion

3A. Acute/Emergent

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Blood pressure reduction: Nicardipine IV (CPT 96365)	IV	-	5 mg/h :: IV :: - :: 5 mg/h IV; increase by 2.5 mg/h q5-15min; max 15 mg/h. Target SBP 130-150 mmHg (INTERACT2: <140 safe; AHA 2022: <140 reasonable if presenting SBP 150-220)	Severe aortic stenosis; advanced HF	Continuous arterial line BP; neuro checks with each change; avoid SBP <110 (renal hypoperfusion)	STAT	STAT	-	STAT
Blood pressure reduction: Labetalol IV (CPT 96374)	IV	-	10-20 mg :: IV :: once :: 10-20 mg IV bolus over 1-2 min; may repeat or double q10min; max 300 mg. Alternative to nicardipine	Heart block (2nd/3rd degree); severe bradycardia; decompensated HF; asthma	HR; BP continuous	STAT	STAT	-	STAT
Blood pressure reduction: Clevidipine IV (CPT 96365)	IV	-	1-2 mg/h :: IV :: - :: 1-2 mg/h IV; titrate by doubling q90sec initially; max 32 mg/h	Soy/egg allergy; lipid disorders	BP continuous	STAT	STAT	-	STAT
Intubation and airway protection	-	-	N/A :: - :: once :: GCS ≤8; inability to protect airway; respiratory failure; impending herniation. Use non-depolarizing agents; avoid succinylcholine if elevated ICP (relative)	N/A	Ventilator; head of bed 30°; avoid hyperventilation unless herniation	STAT	STAT	-	STAT
Warfarin reversal: 4-factor PCC (Kcentra) (CPT 96374)	IV	-	25-50 units/kg :: IV :: - :: 25-50 units/kg IV (dose based on INR: INR 2-4: 25 u/kg; INR 4-6: 35 u/kg; INR >6: 50 u/kg); infuse over 10-15 min. Reverses INR within 15-30 min. PREFERRED over FFP (faster, smaller volume)	Active DIC (relative); HIT (contains heparin traces)	INR 15 min after infusion; repeat if INR >1.4; thrombotic risk	STAT	STAT	-	STAT
Warfarin reversal: Vitamin K (phytonadione)	IV	-	10 mg :: IV :: - :: 10 mg IV slow push (over 10 min) to sustain INR correction (PCC is temporary). ALWAYS give WITH PCC	Known severe allergic reaction (rare)	INR at 6h and 24h; anaphylaxis risk (rare with slow IV)	STAT	STAT	-	STAT
Warfarin reversal: FFP (if PCC unavailable)	IV	-	10-15 mL/kg :: IV :: - :: 10-15 mL/kg IV (typically 2-4 units). Slower than PCC; requires thawing and larger volume	Volume overload; transfusion reactions	INR; volume status	STAT	STAT	-	STAT
Dabigatran reversal: Idarucizumab (Praxbind) (CPT 96374)	IV	-	5 g :: IV :: - :: 5 g IV (two 2.5g boluses or infusions). Specific reversal agent for dabigatran. Reversal within minutes	None absolute	Thrombin time (TT), aPTT; clinical hemostasis	STAT	STAT	-	STAT
Factor Xa inhibitor reversal: Andexanet alfa (Andexxa) (CPT 96365)	IV	-	400 mg :: IV :: once :: For rivaroxaban/apixaban. Low-dose: 400 mg IV bolus then 4 mg/min x 2h (last dose >8h ago). High-dose: 800 mg IV bolus then 8 mg/min x 2h (last dose <8h ago or unknown, or rivaroxaban)	Thrombotic risk (10-15% VTE in trials)	Anti-Xa levels; thrombosis monitoring; arterial line	STAT	STAT	-	STAT
Factor Xa inhibitor reversal: 4-factor PCC (if andexanet unavailable)	IV	-	50 units/kg :: IV :: - :: 50 units/kg IV. Off-label but supported by guidelines if andexanet not available	Same as PCC	Anti-Xa levels; clinical hemostasis	STAT	STAT	-	STAT
Heparin reversal: Protamine sulfate	IV	-	1 mg :: IV :: - :: 1 mg per 100 units of heparin given in last 2-3h; max 50 mg; give slow IV over 10 min	Fish/protamine allergy	aPTT; BP (hypotension with rapid infusion); anaphylaxis	STAT	STAT	-	STAT
Platelet transfusion	-	-	1 unit :: - :: - :: 1 unit apheresis platelets if platelet count <100,000 AND active bleeding or pre-surgical. For antiplatelet-associated ICH: PATCH trial showed NO benefit from routine platelet transfusion (do NOT transfuse if platelets >100K on antiplatelet therapy)	HIT; ITP (consult hematology)	Platelet count; clinical hemostasis	STAT	STAT	-	STAT
Tranexamic acid (TXA)	IV	-	1 g :: IV :: - :: 1 g IV over 10 min then 1 g IV over 8h. TICH-2 trial: did NOT reduce mortality but reduced hematoma expansion. Not routine; consider if spot sign positive or early presentation with active expansion	Active DVT/PE; hypercoagulable state	Thrombotic events; clinical hemostasis	STAT	STAT	-	STAT
ICP management: Head of bed elevation	-	-	N/A :: - :: continuous :: HOB 30°; head in midline (optimize venous drainage); avoid neck flexion/compression	None	ICP if monitored	STAT	STAT	-	STAT
ICP management: Mannitol 20%	IV	-	1-1.5 g/kg :: IV :: once :: 1-1.5 g/kg IV bolus for acute herniation; 0.25-0.5 g/kg q4-6h maintenance	Anuria; serum osm >320	Serum osm q4-6h; osmolar gap; Cr; I/O	STAT	-	-	STAT
ICP management: Hypertonic saline 23.4%	IV	-	30 mL :: IV :: once :: 30 mL IV bolus via central line over 10-20 min for acute herniation	No central access	Na (target 145-155); osmolality	-	-	-	STAT
ICP management: Hypertonic saline 3%	IV	-	150-500 mL :: IV :: once :: 150-500 mL bolus or 0.5-1 mL/kg/h infusion; target Na 145-155	Hypernatremia >160	Na q4-6h; osmolality	-	-	-	STAT

3B. Symptomatic Treatments

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Levetiracetam	IV	Seizure treatment (NOT routine prophylaxis — AHA 2022 recommends against routine prophylaxis). Treat if clinical or electrographic seizures	1000-1500 mg :: IV :: BID :: 1000-1500 mg IV load; then 500-1000 mg IV/PO BID	Severe renal impairment (dose adjust)	Seizure monitoring; cEEG; renal function	STAT	STAT	-	STAT
Acetaminophen	IV	Fever (target normothermia <37.5°C; fever worsens ICH outcomes)	650-1000 mg :: IV :: q6h :: 650-1000 mg PO/IV q6h; max 4g/day	Severe hepatic disease	Temperature q4h; LFTs	STAT	STAT	-	STAT
Surface cooling / Arctic Sun	-	Refractory fever (targeted temperature management)	N/A :: - :: per protocol :: Target 36-37°C; avoid shivering (counterproductive)	N/A	Core temperature; shivering assessment (BSAS)	-	-	-	ROUTINE
Insulin (regular)	IV	Hyperglycemia (target 140-180 mg/dL)	N/A :: IV :: continuous :: Sliding scale or insulin drip	Hypoglycemia	BG q1h if drip; q6h if sliding scale	STAT	STAT	-	STAT
Pantoprazole	IV	GI prophylaxis (Cushing ulcer risk from elevated ICP)	40 mg :: IV :: daily :: 40 mg IV/PO daily	C. diff risk	GI symptoms	-	ROUTINE	-	ROUTINE
Enoxaparin	SC	DVT prophylaxis (start 24-48h after hemorrhage stabilizes; after repeat CT shows stability)	40 mg :: SC :: daily :: 40 mg SC daily. AHA 2022: intermittent pneumatic compression devices on admission; pharmacologic prophylaxis after hemorrhage stable on repeat imaging	Active hemorrhagic expansion; within 24h of ICH onset; pre-surgical	Platelet count; repeat CT before starting	-	ROUTINE	-	ROUTINE
Pneumatic compression devices	-	DVT prophylaxis (start IMMEDIATELY)	N/A :: - :: continuous :: Apply bilaterally on admission; ICH patients are HIGH VTE risk	Acute DVT	Skin checks	STAT	STAT	-	STAT
Ondansetron	IV	Nausea/vomiting (posterior fossa hemorrhage; elevated ICP)	4 mg :: IV :: q6h :: 4 mg IV q6h PRN	QT prolongation	QTc	STAT	ROUTINE	-	STAT

3C. Surgical Interventions

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
External ventricular drain (EVD)	-	IVH with acute hydrocephalus; GCS declining; need for ICP monitoring	N/A :: - :: once :: Neurosurgery places; allows CSF drainage and ICP monitoring; target ICP <22, CPP >60	Coagulopathy (correct first); futile care	-	-	-	-	-
Intraventricular tPA via EVD	-	IVH with hydrocephalus (CLEAR III trial: reduced mortality in severe IVH but did NOT improve functional outcome)	1 mg :: - :: q8h :: Alteplase 1 mg q8h via EVD; up to 12 doses; clamp EVD 1h after dosing then open to drain	Active systemic bleeding; coagulopathy	-	-	-	-	-
Surgical hematoma evacuation (craniotomy)	-	Lobar ICH >30 mL with deterioration; cerebellar hemorrhage >3 cm OR with brainstem compression/hydrocephalus (STRONGEST surgical indication). STICH/STICH-II: no clear benefit for supratentorial deep ICH	N/A :: - :: once :: Craniotomy or craniectomy for clot evacuation	Deep ICH (generally no benefit from open surgery); GCS 3-4 without brainstem reflexes (futile); severe coagulopathy	-	-	-	-	-
Minimally invasive surgery (MIS) — endoscopic or stereotactic aspiration	-	Supratentorial ICH >30 mL with stable or mild deficits (MISTIE III, ENRICH trials: emerging data; ENRICH showed benefit for lobar ICH)	N/A :: - :: once :: Stereotactic catheter-based aspiration or endoscopic evacuation with lower morbidity than craniotomy	Deep location (relative); coagulopathy	-	-	-	-	-
Decompressive craniectomy	-	Massive ICH with refractory elevated ICP; malignant cerebellar edema	N/A :: - :: once :: Bone flap removal to allow brain expansion	Futile prognosis; bilateral fixed dilated pupils	-	-	-	-	-
Suboccipital decompressive craniectomy	-	Cerebellar hemorrhage with brainstem compression	N/A :: - :: once :: Posterior fossa decompression; life-saving for cerebellar ICH with brainstem compression	Moribund patient	-	-	-	-	-

3D. Secondary Prevention (After Acute Phase)

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Antihypertensive therapy (long-term)	PO	ALL ICH patients; BP is most important modifiable risk factor	N/A :: PO :: per protocol :: Target SBP <130 mmHg (SPS3 trial, PROGRESS trial); agent choice per comorbidities (ACE-I, ARB, CCB, thiazide)	-	-	Home BP monitoring; clinic BP	-	-	-	-
Statin (controversial post-ICH)	PO	Risk-benefit discussion; SPARCL showed small increased ICH risk with atorvastatin but overall cardiovascular benefit. AHA 2022: statin not contraindicated after ICH	N/A :: PO :: per protocol :: Per cardiovascular risk; individualize	-	-	Lipid panel	-	-	-	-
Anticoagulation restart (if AF or mechanical valve)	PO	Most controversial decision. AHA 2022: may restart anticoagulation at 4-8 weeks for patients with strong indication (AF with high CHA2DS2-VASc). Avoid in CAA-related lobar ICH if possible	N/A :: PO :: per protocol :: Apixaban preferred (APACHE-AF trial: lowest ICH recurrence). Timing: 4-8 weeks; individualized risk-benefit	-	-	Imaging stability; bleeding risk; CHA2DS2-VASc vs HAS-BLED	-	-	-	-
Antiplatelet restart	PO	RESTART trial: restarting antiplatelet after ICH is associated with LOWER risk of recurrent ICH; may restart at 2-4 weeks for patients with cardiovascular indication	81 mg :: PO :: daily :: Aspirin 81 mg or clopidogrel 75 mg daily	-	-	Bleeding signs	-	-	-	-
Left atrial appendage occlusion (LAAO/Watchman)	Procedure	AF patients who cannot tolerate long-term anticoagulation post-ICH (lobar ICH, CAA)	N/A :: Procedure :: per protocol :: Interventional cardiology procedure; eliminates need for long-term anticoagulation in AF	-	-	Procedural risks	-	-	-	-

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4. OTHER RECOMMENDATIONS

4A. Referrals & Consults

Recommendation	ED	HOSP	OPD	ICU	Indication
Neurosurgery	STAT	STAT	-	STAT	ALL ICH patients; surgical decision for EVD, hematoma evacuation, decompression
Neurology / Neurocritical care	STAT	STAT	-	STAT	Medical management; BP optimization; ICP management; seizure management
Hematology	STAT	STAT	-	STAT	Anticoagulant reversal guidance; coagulopathy management; thrombocytopenia
Pharmacy (clinical pharmacist)	STAT	STAT	-	STAT	Reversal agent dosing; anticoagulant identification; drug interactions
Cardiology	-	ROUTINE	ROUTINE	ROUTINE	AF management; anticoagulation restart decision; LAAO evaluation; neurogenic cardiac injury
Speech-language pathology (SLP)	-	URGENT	ROUTINE	URGENT	Dysphagia screening before PO intake; aphasia assessment
Physical therapy (PT)	-	URGENT	ROUTINE	URGENT	Early mobilization (24-48h if stable); fall prevention; strength
Occupational therapy (OT)	-	URGENT	ROUTINE	URGENT	ADL assessment; cognitive rehabilitation; adaptive equipment
Rehabilitation medicine (physiatry)	-	ROUTINE	ROUTINE	-	Rehabilitation disposition; functional prognosis
Social work	-	ROUTINE	ROUTINE	-	Family support; advance directives; discharge planning
Palliative care	-	ROUTINE	-	ROUTINE	Goals of care discussion (especially ICH score ≥3); early palliative involvement improves care quality
Interventional neuroradiology	-	ROUTINE	-	ROUTINE	AVM/aneurysm treatment planning; dural AV fistula

4B. Patient / Family Instructions

Recommendation	ED	HOSP	OPD
ICH is serious but outcomes vary; early aggressive treatment improves survival	STAT	ROUTINE	ROUTINE
Call 911 if: sudden headache, new weakness, speech changes, altered consciousness	-	ROUTINE	ROUTINE
Blood pressure control is the MOST IMPORTANT factor in preventing recurrence	-	ROUTINE	ROUTINE
Take all medications as prescribed; never stop blood pressure medications without physician guidance	-	ROUTINE	ROUTINE
Do NOT restart anticoagulation or antiplatelet without specific neurology/cardiology guidance	-	ROUTINE	ROUTINE
Home blood pressure monitoring daily; keep log; target per physician guidance	-	ROUTINE	ROUTINE
Follow-up with neurology in 2-4 weeks; neurosurgery if applicable	-	ROUTINE	ROUTINE
Do NOT drive until cleared	-	ROUTINE	ROUTINE
Fall prevention at home	-	ROUTINE	ROUTINE

4C. Lifestyle & Prevention

Recommendation	ED	HOSP	OPD
Blood pressure target <130/80 mmHg (most important)	-	ROUTINE	ROUTINE
Smoking cessation (doubles ICH risk)	-	ROUTINE	ROUTINE
Alcohol cessation or limitation (heavy drinking increases ICH risk)	-	ROUTINE	ROUTINE
Cocaine/amphetamine cessation (sympathomimetic ICH)	-	ROUTINE	ROUTINE
Avoid excessive anticoagulation (keep INR in range if on warfarin)	-	ROUTINE	ROUTINE
Regular exercise (moderate intensity after recovery)	-	-	ROUTINE
Weight management	-	ROUTINE	ROUTINE
DASH or Mediterranean diet	-	ROUTINE	ROUTINE
Depression screening (PHQ-9 at 1-3 months)	-	-	ROUTINE

═══════════════════════════════════════════════════════════════ SECTION B: REFERENCE (Expand as Needed) ═══════════════════════════════════════════════════════════════

5. DIFFERENTIAL DIAGNOSIS

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Hemorrhagic transformation of ischemic stroke	Prior ischemic infarct on imaging; onset timing suggests ischemic → hemorrhagic evolution	CT/MRI timing; DWI changes preceding hemorrhage
Cerebral venous thrombosis (CVT) with hemorrhagic infarct	Headache, seizures, often young women (OCPs, pregnancy); hemorrhage doesn't respect arterial territory; parasagittal location	MRV/CT venography (thrombosed sinus); D-dimer
Brain tumor with hemorrhage	Subacute symptoms preceding hemorrhage; ring enhancement around hemorrhage; disproportionate edema	MRI with contrast (underlying enhancing mass); biopsy
Cerebral amyloid angiopathy (CAA)	Lobar location (NOT deep); age >55; recurrent lobar hemorrhages; cortical superficial siderosis; multiple lobar microbleeds on SWI	MRI SWI (lobar microbleeds, superficial siderosis); Boston criteria
Vascular malformation (AVM, cavernoma)	Younger patient; recurrent hemorrhages at same location; AVM on CTA/DSA; cavernoma on MRI (popcorn appearance)	CTA; DSA; MRI (especially SWI)
Ruptured aneurysm extending into parenchyma	Subarachnoid + intraparenchymal hemorrhage; near aneurysm location	CTA (aneurysm); DSA
Hypertensive ICH	Deep location (putamen, thalamus, pons, cerebellum); history of poorly controlled HTN	Clinical; typical location; no underlying lesion on workup
Moyamoya disease	Young adults or Asian patients; recurrent stroke; stenotic proximal vessels with collateral network	MRA (ICA/MCA stenosis with Moyamoya collaterals); DSA
Coagulopathy-related ICH	Multiple hemorrhages; known coagulopathy or anticoagulant use	Coagulation panel; medication history
Mycotic aneurysm	Endocarditis; distal vessel location; fever	Blood cultures; echocardiogram; CTA/DSA
Trauma	History of trauma; scalp laceration; subdural or epidural components	Clinical history; CT pattern

6. MONITORING PARAMETERS

Parameter	ED	HOSP	OPD	ICU	Frequency	Target/Threshold	Action if Abnormal
Blood pressure (arterial line preferred in ICU)	STAT	STAT	ROUTINE	STAT	q5min x 2h during acute reduction; q15min x 6h; then q1h x 24h; then q4h	SBP 130-150 (acute); <130/80 (chronic)	Titrate antihypertensives; avoid SBP <110
GCS / Neurologic exam	STAT	STAT	ROUTINE	STAT	q1h x 24h, then q2h x 24h, then q4h	Stable or improving GCS	If declining: STAT CT; ICP assessment; neurosurgery
ICP (if EVD in place)	-	-	-	STAT	Continuous; assess q1h	ICP <22 mmHg; CPP 60-70 mmHg	Tiered ICP management: drain CSF → osmotherapy → sedation → hypothermia → decompression
Repeat CT head	-	STAT	-	STAT	At 6h (routine); at 24h; and with ANY neurologic decline	Stable hematoma; no expansion (>33% or >6mL = expansion)	If expanding: re-evaluate BP; reversal; surgical consultation
Temperature	STAT	STAT	-	STAT	q4h; q1h if febrile	<37.5°C (normothermia)	Aggressive fever management; cooling devices; infection workup
Blood glucose	STAT	STAT	-	STAT	q6h (q1h if insulin drip)	140-180 mg/dL	Insulin; avoid <60
Serum sodium	-	ROUTINE	-	STAT	q6h during osmotherapy; q12h otherwise	135-155 (higher range with osmotherapy)	Adjust osmotherapy
Serum osmolality	-	ROUTINE	-	STAT	q6h during mannitol	<320 mOsm/kg; osmolar gap <10	Hold mannitol if >320
INR (if on warfarin)	STAT	ROUTINE	-	STAT	15 min after PCC; then q6h x 24h; then daily	INR <1.4	Additional reversal agents
Hemoglobin	STAT	ROUTINE	-	ROUTINE	q6-12h x 48h	>7 g/dL (>10 if active bleeding or coronary disease)	Transfuse PRBCs
EEG / Seizure monitoring	-	URGENT	-	STAT	cEEG 24-48h minimum if altered consciousness	No seizure activity	AED loading; aggressive management
Swallowing screen	-	STAT	-	URGENT	Before any PO intake	Pass screening	NPO; SLP evaluation
ICH Score (calculate at admission)	STAT	-	-	STAT	Once (prognostic)	Lower is better	Goals of care discussion if score ≥3

7. DISPOSITION CRITERIA

Disposition	Criteria
Discharge home	Small ICH; stable exam; GCS 15; ambulatory; adequate home support; medications filled; BP controlled; follow-up arranged
Admit to stroke unit/floor (monitored)	Small-moderate ICH; GCS 13-15; no surgical indication; stable repeat CT; BP controlled on oral/IV medications
Admit to neuro-ICU	ALL moderate-large ICH; GCS <13 or declining; anticoagulant-related ICH; posterior fossa ICH; IVH with hydrocephalus; EVD in place; requiring arterial line and IV antihypertensives; post-surgical
Emergent surgery	Cerebellar ICH >3 cm with brainstem compression or hydrocephalus; deteriorating lobar ICH >30 mL; obstructive hydrocephalus needing EVD
Transfer to higher level	Need for neurosurgery not available; need for neuro-ICU; need for reversal agents not available; need for endovascular treatment
Inpatient rehabilitation	Significant deficits but able to participate in 3h/day therapy; medically stable
Comfort care / Hospice	ICH score ≥4; devastating ICH with poor prognosis after family goals of care discussion

8. EVIDENCE & REFERENCES

Recommendation	Evidence Level	Source
SBP target <140 mmHg in acute ICH (presenting SBP 150-220)	Class I, Level A	INTERACT2 (Anderson et al. NEJM 2013); AHA/ASA 2022 Guidelines
Intensive BP lowering safe but benefit on functional outcome modest	Class IIa, Level A	ATACH-2 (Qureshi et al. NEJM 2016) — <140 vs <180 safe; no functional difference
4-factor PCC preferred over FFP for warfarin reversal	Class I, Level B	INCH trial (Steiner et al. Lancet Neurol 2016)
Idarucizumab for dabigatran reversal	Class I, Level B	RE-VERSE AD trial (Pollack et al. NEJM 2017)
Andexanet alfa for factor Xa inhibitor reversal	Class IIa, Level B	ANNEXA-4 (Connolly et al. NEJM 2019)
Platelet transfusion NOT beneficial for antiplatelet-associated ICH	Class III (No Benefit)	PATCH trial (Baharoglu et al. Lancet 2016)
TXA reduces expansion but NOT mortality	Class IIb, Level B	TICH-2 (Sprigg et al. Lancet 2018)
Surgical evacuation for cerebellar ICH with deterioration	Class I, Level B	AHA/ASA Guidelines; strong consensus
No benefit from routine supratentorial open surgery	Class III (No Benefit)	STICH (Mendelow et al. Lancet 2005); STICH II (2013)
Minimally invasive surgery emerging benefit	Class IIb, Level B	MISTIE III (Hanley et al. Lancet 2019); ENRICH (2024)
EVD for IVH with hydrocephalus	Class I, Level B	AHA/ASA Guidelines
Intraventricular tPA (CLEAR III)	Class IIb, Level B	Hanley et al. (Lancet 2017) — reduced mortality but not functional outcome
Seizure prophylaxis NOT recommended routinely	Class III (No Benefit)	AHA/ASA 2022 — treat clinical/electrographic seizures; cEEG if altered
Anticoagulation restart 4-8 weeks for AF	Class IIb, Level B	AHA/ASA 2022; observational data
Antiplatelet restart appears safe (RESTART trial)	Class IIa, Level B	RESTART trial (Lancet 2019)
DVT prophylaxis: pneumatic devices immediately; pharmacologic at 24-48h	Class I, Level B	AHA/ASA 2022 Guidelines
ICH Score for prognosis	Class IIa, Level B	Hemphill et al. (Stroke 2001)
Normothermia improves outcomes	Class I, Level C	AHA/ASA Guidelines
Avoid self-fulfilling prophecy (DNR discussion timing)	Class I, Level C	AHA/ASA 2022: delay new DNR orders until at least 24h after admission

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APPENDIX: ICH SCORE (PROGNOSIS)

Component	Points
GCS 3-4	2
GCS 5-12	1
GCS 13-15	0
ICH volume ≥30 mL	1
ICH volume <30 mL	0
IVH present	1
IVH absent	0
Infratentorial origin	1
Supratentorial origin	0
Age ≥80	1
Age <80	0

ICH Score	30-Day Mortality
0	0%
1	13%
2	26%
3	72%
4	97%
5	100%

APPENDIX: ABC/2 METHOD FOR ICH VOLUME

Volume (mL) = (A × B × C) / 2 - A = largest diameter on slice with largest hemorrhage (cm) - B = diameter perpendicular to A on same slice (cm) - C = number of CT slices with hemorrhage × slice thickness (cm)

APPENDIX: ANTICOAGULANT REVERSAL QUICK REFERENCE

Agent	Reversal	Dose	Onset
Warfarin	4-factor PCC + Vitamin K 10mg IV	Per INR (25-50 u/kg)	15-30 min
Dabigatran	Idarucizumab (Praxbind)	5g IV	Minutes
Rivaroxaban/Apixaban	Andexanet alfa (Andexxa) OR 4-factor PCC 50 u/kg	Per dosing protocol	15-30 min
Edoxaban	Andexanet alfa OR 4-factor PCC 50 u/kg	Per protocol	15-30 min
UFH	Protamine sulfate	1mg per 100u heparin	Minutes
LMWH	Protamine sulfate (60% reversal)	1mg per 1mg enoxaparin (within 8h)	Partial