DEPARTMENT OF CRITICAL CARE ICH Version 2

CLINICAL GUIDELINE

Guidelines for the Management of Intracerebral Haemorrhage

AIM: To provide guidance on the management of patients with intracerebral haemorrhage.

SCOPE: All adult ICUs within Brighton and Sussex University Hospitals

EMERGENCY Clinical suspicion of ICH

DEPARTMENT

Initial ABCDE management and imaging (CTH)

Consider early requirement for mechanical

ventilation and sedation

Systolic BP control 140-160 mmHg Neurosurgical review and decision for:

Optimise/reverse coagulation parameters • Surgery or conservative

• EVD
ICP optimisation • ICP

NEURO ICU Intracranial pressure monitoring (ICP<20 mm Hg)

CPP 50-70 mmHg

Normocarbia (pCO2 4.5-5 kPA)

SBP 140-170 mmHg

Maintain euvolaemia

Maintain Na 140-150 mmol/L

Optimise coagulopathy

Seizure management/prophylaxis

Normothermia

Further imaging (interval or investigatory for Secondary ICH)

Nutrition

Bowel Management

Mechanical Thromboprophylaxis (in initial stages)

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1. INTRODUCTION
Epidemiology

Intracerebral/cerebellar haemorrhage represents approximately 10% of strokes with an incidence of

16 – 33 per 100000 (Rodorf). It often presents like stroke but tends to be more dramatic associated
with nausea and vomiting and is more likely to lead to coma. Principal causes are micro-aneurysmal
rupture and degeneration of small, deep penetrating arteries, in the context of chronic hypertension.
Rarer causes include AVM and Amyloid deposition (Kumar).

Pathophysiology and Risk Factors

Damage is caused initially by direct mechanical damage of the clot itself and cytotoxic peri-lesional
oedema. Secondary contributing factors are not well understood but are thought to include disruption
of the protective BBB, disrupted cerebral autoregulation leading to local ischaemia, thrombin induced
activation of inflammatory cascades leading to local cell damage. Haematoma enlargement is also
an issue and is thought to be associated with higher SBP targets, antithrombotic therapy, large
haematoma size and extravasation of contrast on CT.

Diagnosis is principally via plain CT which can locate and characterise the lesion and show spread to
ventricles and mass effect. Volume in cm^3 can be estimated. In comparison MRI is as effective as
CT in detecting acute bleeds but is more effective in detecting chronic bleeds. MRI also has a role to
play in detecting underlying causes such as AVM. The role of further investigation for underlying
causes is a subtle decision.

If a patient has marked hypertension and haemorrhage affecting a typical part of the brain (Pons,
caudate nucleus, putamen/internal capsule, thalamus or cerebellum) then one can declare
hypertension or trauma as the probable cause. Otherwise, one may need to investigate for bleeding
disorder, tumour or AVM in normotensive patients with lobar haemorrhage.

In cerebellar haemorrhage, signs may indicate the brainstem origin – nystagmus, gaze deviation
towards the side of the haemorrhage, uni or bilateral cerebellar signs in an awake patient.

Risk factors: Hypertension, older age, high alcohol intake, Afro-Caribbean descent, low cholesterol,
low triglycerides, anti-coagulation with Warfarin, cocaine and methamptamine,

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CLINICAL GUIDELINE

Date: Revised Aug 2018 Revision Date: Aug 2020 Authors: MT/IHL/TC/JN/BM/JW
DEPARTMENT OF CRITICAL CARE ICH Version 2
CLINICAL GUIDELINE

Table 1: Scoring systems

Clinical scoring (Hemphill):

Component ICH Score Points

GCS 3-4 2

5-12 1

13-15 0

ICH volume cm3 >30 1

<30 0

IVH Yes 1

No 0

Infra-Tentorial origin of ICH Yes 1

No 0

Age >/= 80 1

<80 0

Total ICH score 0-8

GCS score indicates GCS score on initial presentation (or after resuscitation); ICH volume, volume
on initial CT calculated using ABC/2 method; and IVH, presence of any IVH on initial CT

2. PROCESS

Scoring systems and diagnosis

Recommendation
Justification (Rationale)
(Action)
The use of a scoring Thirty-day mortality rates for patients with ICH Scores of 1, 2, 3,
system predicts and 4 were reported as 13%, 26%, 72%, and 97%, respectively.
mortality (see table 1) Overall mortality is in excess of 40%.

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Recommendation
Justification (Rationale)
(Action)
Diagnosis is principally CT can locate and characterise the lesion and show spread to
via plain CT ventricles and mass effect. Volume in cm^3 can be estimated. In
comparison MRI is as effective as CT in detecting acute bleeds
but is more effective in detecting chronic bleeds. MRI also has a
role to play in detecting underlying causes such as AVM. The
role of further investigation for underlying causes is a subtle
decision.

If a patient has marked hypertension and haemorrhage affecting

a typical part of the brain (Pons, caudate nucleus, putamen/
internal capsule, thalamus or cerebellum) then one can declare
hypertension or trauma as the probable cause. Otherwise, one
may need to investigate for bleeding disorder, tumour or AVM in
normotensive patients with lobar haemorrhage.

In cerebellar haemorrhage, signs may indicate the brainstem

origin – nystagmus, gaze deviation towards the side of the
haemorrhage, uni or bilateral cerebellar signs in an awake
patient.

Medical Management

Recommendation (Action) Justification (Rationale)

Airway Early mechanical ventilation with sedation is advised in

the following patients:

• Worsening cerebral agitation

• fluctuating GCS

• Deteriorating GCS

• Developing focal neurology

• Evidence of seizures

• Evidence of rising intracranial

pressure

• GCS less than or equal to 8

Ventilation Normocarbia (4.5-5) should be maintained

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Recommendation (Action) Justification (Rationale)

Blood pressure Aim SBP 140-179 but discuss with neurosurgeryEnsure

control there are no contraindications for lowering blood pressure
and AVOID HYPOTENSION.

The actual blood pressure targets are controversial and

should be discussed with neurosurgery as hypotension
may cause ischemia but hypertension may result in
extension of the haematoma.

INTERACT 2(1)

The INTERACT 2 trial looked at immediate blood

pressure control to SBP < 140 within 1 hour of
presentation and maintained for the first 7 days
on admission in patients with ICH who presented
with a SBP of 150-220, compared to standard
therapy (SBP <180). There was a statistically
significant benefit in the reducing SBP to <140
improving functional outcome (modified Rankin
Scores).

Please note that it excluded patients with structural

etiology for ICH, GCS <5, massive haematoma
with poor prognosis, or those planned urgent
evacuation of haematoma. (1)

ATACH2 (2)

The ATACH 2 trial showed that patients whose

systolic blood pressure was reduced to the
standard levels used to treat acute stroke (140 to
179 mm Hg) fared as well as patients who
underwent intensive blood pressure reduction
(110 to 139 mm Hg) with intravenous nicardipine.
Primary outcomes (death and severe disability
were observed in 38.7% of participants in the
intensive treatment group versus 37.7% in the
standard treatment group. Serious adverse
events that occurred with 72 hours of blood
pressure reduction that were determined to be a
result of treatment occurred in 1.6% of patients in
the intensive treatment group and in 1.2% of
those in the standard treatment group. The
intensive treatment group had a significantly
higher rate of renal adverse events within 7 days
compared with the standard treatment group
(9.0% versus 4.0%).

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Recommendation (Action) Justification (Rationale)

Antihypertensive The American Heart Association have recommended the

Medication following antihypertensives in ICH(3)

• Labetalol

• Esmolol

• Nicardipine

• Enalapril

In our unit the antihypertensive of choice is Labetalol as

an IV Infusion. Initially 20mg/hthen increased in 20
minute increments to 40mg/h,80gm/h up to a maximum of
160 mg/min.

Labetalol is usually prepared in 5% dextrose or sodium

chloride and dextrose diluted to 1mg/min but ? may need
to be more concentrated if problems with fluid balance. ?
need to check with pharmacy.

NB If patient intubated and sedated make sure

sedation is adequate before initiating
antihypertensive therapy.

Patients with premorbid hypertension will need more long

term management of blood pressure as they recover from
initial injury as poorly controlled blood pressure is
associated with recurrence. ( Biffi et al).

ICP monitoring ICP monitoring is recommended in the following patients

who are under sedation and unable to be neurologically
assessed.(2)

• GCS low (<8) at time of intubation

• Large volume ICH

• Evidence of mass effect on imaging

• Intraventricular blood

• Hydrocephalus

• Tentorial herniation or at risk of it.

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Recommendation Justification (Rationale)

(Action)
Target ICP Aim for ICP< 20mmH20

Ensure ICP is well controlled with the following:

• Optimised cerebral venous return and venous return

o Ensure 30 degree head elevation

o Loosen ETT ties, loosen hard collar if too

tight

o Avoid hip flexion beyond 90 degrees

o Avoid hyperextension of neck

• Adequate sedation

• Normothermia

• Good ventilator synchrony

Manage raised ICP There may be clinical signs of intracranial pressure (3rd or 6th
nerve palsy, bradycardia, hypertension, ICP >20). If ICP >
20mmH20 sustained for > 5 minutes, call neurosurgeons
(CTH/EVD/surgical intervention to be considered)

Please refer to the appendix for the protocol for managing

raised ICP.

Cerebral Perfusion Aim for cerebral perfusion pressure 50-70mmHg.

Pressure
Tranexamic acid There is currently no evidence for the use of
tranexamic acid in ICH small unrandomised
studies have suggested a beneficial effect and
this is currently subject large RCT. (4)

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Reversal of patients on anticoagulation/antiplatelets: Specific advice

Recommendation Justification (Rationale)

(Action)
Patients on • Withholding of anticoagulation and rapid correction of
anticoagulation has been recommended in ICH.
vitamin K
antagonists • Vitamin K 5-10mg (IV) and FFP is given as soon as
(Warfarin) possible. Vitamin K has an onset in 2 hours, and maximal
effect in 24 hours assuming adequate liver function(5).
Goldstein et al. showed that every 30 minute delay in FFP
administration was associated with a 20% reduction in odds of
reversal of INR in patients with ICH in the first 24 hours of
admission(6).

• The use of prothrombin complex concentrate has been

assessed through a Cochrane review. Although INR corrects
faster and earlier administration of the product is possible (no
thawing or cross-matching needed), there seems to be no
difference in mortality or difference in transfusion requirements.
However, none of the RCTSs used were powered to detect
mortality, benefit, and harm(7). As such, further research is
required.

• The use of rFVIIa has also shown to reverse INR much

faster than FFP, however higher powered studies are needed
to show improved outcomes in ICH(8;9).

Patients on • Protamine is used to reverse heparin. Please contact

unfractionated Pharmacy for the calculated dose (dose is dependent on the
amount of heparin that the patient has had.)
Heparin
Patients on anti • Medical Management: The PATCH study (RCT of 190
platelet therapy patients with spontaneous supratentorial ICH) concluded that
platelet transfusion therapy cannot be recommended in
patients with ICH on antiplatelet therapy(10). A meta-analysis
of 6 studies of the use of platelets in ICH revealed no
difference in survival outcomes (11).

• Neurosurgical intervention: The use of platelets in

patients who require urgent neurosurgical intervention should
be decided by the neurosurgeon and haematologist.
Traditionally, neurosurgical intervention requires a platelet
count of greater than 100.

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Recommendation Justification (Rationale)

(Action)
Patients on other Requires consultation with haematologist (2)
anticoagulants
• Commonly used agents include Tranexamic acid, PCC
e.g.LMWH,
and rFactor VII
fondoparinaux,
rivaroxaban, apixaban, • All patients on the following drugs should have levels
dabigatran,) done with a clotting sample sent at the same time.
Initial clotting results should be discussed with the
haematologist oncall as they will give an indication of
how much systemic anticoagulant is remaining as well
as the type of anticoagulant (if this is unknown). The
name of the drug, the dose and time of the last dose
must be provided when sending the sample (if known).

a. Dabigatran (renally excreted): TT and APTT

are prolonged
b. Apixaban: can prolong INR, however no
abnormality is seen normally.
c. Rivaroxaban: Very sensitive to INR, thus INR
will be very high
• Specific anticoagulants

a. Anti Xa inhibitors: A factor Xa inhibitor

antidote (Andexanet alpha) is currently in
phase 3 clinical trial (ANNEXA-4) and will
hopefully be available shortly (apixaban,
rivaroxaban, edoxaban or enoxaparin). In the
meantime, the following may be considered on
discussion with the haematologist.
Subcutaneous:

1. Low molecular weight heparin

(dalteparin, enoxaparin,
tinzaparin): Protamine,
however reversal may be
partial. Please contact
Pharmacy for the dose.

2. Fondoparinaux: rFVIIa may be

considered

Oral

1. Rivaroxaban: PCC may be

considered

2. Apixaban: PCC may be

considered

b. Anti IIa

i. Dabigatran: Reversal (Praxbind:

idarucizumab) is available from blood
transfusion or with Octaplex in the A
&E department. Haemodialysis may
be considered
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Other medical measures

Recommendation (Action) Justification (Rationale)

Anticonvulsants Prophylaxis: The incidence of seizures has been

reported as low as 6.2 % and as high as 40%,
depending on the location and extent of ICH. An
observational study has suggested that phenytoin
prophylaxis is associated worse outcomes.
However there has been not been a large study yet
to systematically elucidate the correlations between
size, location, timing of ICH with seizure
prophylaxis. ICHs with subarachnoid extension, and
cortical involvement have been associated with
higher risk for seizures (12-14).

Prophylaxis
Consider prophylaxis with the following although not
recommended (3):

• Subarachnoid extension

• Cortical involvement in lobar ICH

We would recommend one of the following

antiepileptics:

• Levetiracetam 500mg BD

• Phenytoin 15-20mg/kg followed by 300mg

OD

Management of seizures: (continuous EEG

monitoring is recommended)

• First line: benzodiazepine. If the patient is

sedated, ensure pt is fully sedated

• Second line: Phenytoin loading or

Levetiracetam (dosage as above).
Levetiracetam: in resistant seizures, a
250mg bolus followed by an increase by
250mg BD up to 1500mg BD.

• Third line: Phenytoin or Levetiracetam

(which ever has not been used yet)

• Fourth line: Sodium Valproate

• Fifth line: Consider thiopental (discussion

with ICU consultant first)

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Recommendation (Action) Justification (Rationale)

Temperature Control • Normothermia is recommended.

• Fever is common in ICH and is associated
with poor neurological outcome (15;16). An
observational study has correlated fever with
increased ICH volume and third ventricular shift
(15).
• Further randomised multicentre trials are
awaited to look at the role of mild hypothermia in
ICH(17).
Glucose Control Normoglycaemia is recommended (6-10mml/L)

Further imaging CTA, CT with contrast or MRI may be useful in

investigating the underlying cause of the ICH. (eg.
Vascular malformation or tumours)

Thromboprophylaxis Intermittent pneumatic compression stockings

arerecommended from the first day of
admission (CLOTS 3)(18)

Early thromboprophylaxis with heparin or low

molecular weight heparin has been shown to reduce
the risk of PE however its effect on haematoma
enlargement remains equivocal. (19). As such,
early thromboprophylaxis can be advised once
neurosurgeons can recommend so and there is no
high risk of re-bleed or high risk for neurosurgical
intervention.

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Surgical Management

Recommendation (Action) Justification (Rationale)

Craniotomy:Supratentorial • Evacuation of spontaneous ICH (Craniotomy)

ICH The STICH (20) and STICH II(21) trials looked at
whether early neurosurgical intervention
improved outcomes in patients with spontaneous
ICH.

• In the STICH trial, there was no significant

difference in outcome between early surgical and
medical management.

• In the STICH II trial, patients with lobar

haemorrhage without intraventricular
haemorrhage were assessed and a non-
significant advantage to outcome was noted in
patients in the early intervention arm. In patients
with poor prognostication subgroup analysis
suggested early surgical intervention was
associated with better neurological outcome
(p=0.02). Overall, the study was unable to prove
that early surgery was associated with
significantly improved outcomes.

• When all trials of surgical intervention in ICH

were analysed together by the STICH authors,
significantly improved outcomes were noted
however the heterogeneity of ICH makes this
result difficult to assess in the context of clinical
applicability. Further RCTs are required.

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Recommendation (Action) Justification (Rationale)

Craniotomy:Posterior Cerebellar ICH

fossa ICH The main factors contributing to mortality are
compression of the brainstem, compression of the fourth
ventricle (causing hydrocephalus), oedema surrounding
the haematoma and expansion of the haematoma.

Brainstem ICH

Brainstem ICH is associated with very poor prognosis

and it is unlikely to improve with surgical intervention(2)

• Compression of the brainstem or compression

of the fourth ventricle

• The American Stroke Association have

recommended evacuation of the haematoma if
any of the following are present

o hydrocephalus from
ventricular obstruction

o brainstem

o It has been suggested that

the need for an EVD due to
hydrocephalus from an
obstructed 4rth ventricle
suggests the requirement of
surgical decompression (22)

Decompresive craniectomy Decompressive craniectomy has been used to alleviate resistant

raised intracranial pressure in TBI(23), SAH(24) and malignant
ischaemic stroke(25). It may have a role in severe ICH however
as shown in a systematic review by Takeuchi et al, a good
quality RCT is required to show clinical effectiveness (26;27).
Minimally invasive Minimally invasive surgery has shown some promising
surgery results and may be implemented in the future
Perihaematomal oedema is a contributor or morbidity. In
the MISTIE trial, medical management revealed 52%
higher perihaematomal oedema than with minimally
invasive surgery. In the surgical arm, a catheter was
placed at the ICH site from where the haematoma was
evacuated with the use of alteplase.(28) A phase III trial
is currently being held.

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Recommendation (Action) Justification (Rationale)

Surgical management of Intraventricular extension of an ICH is associated with a

Intraventricular extension of much worse mortality than ICH alone(29).
ICH or Intraventricular
• Discuss insertion of EVD with neurosurgeons is
Haemorrhage (IVH)
recommended.

• Alteplase in IVH: The CLEAR III trial has

compared the use of alteplase and EVD with
saline washout and EVD in patients with IVH and
small parenchymal haemorrhage (<30cc).
Results are due in 2016 (30).

The endoscopic evacuation of IVH is also unknown at

present.

3. GLOSSARY

SAH Sub-Arachnoid Haemorrhage

TBI Traumatic Brain Injury

4. REFERENCES AND ONLINE RESOURES

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(27) Takeuchi S, Wada K, Nagatani K, Otani N, Mori K. Decompressive

hemicraniectomy for spontaneous intracerebral hemorrhage. Neurosurg Focus
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(28) Mould WA, Carhuapoma JR, Muschelli J, Lane K, Morgan TC, McBee NA, et al.
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for intracerebral hemorrhage evacuaDon decreases perihematomal edema.
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Date: Revised Aug 2018 Revision Date: Aug 2020 Authors: MT/IHL/TC/JN/BM/JW
DEPARTMENT OF CRITICAL CARE ICH Version 2
CLINICAL GUIDELINE

The use of this guideline is subject to professional judgement and accountability. This guideline has been
prepared carefully and in good faith for use within the Department of Critical Care at Brighton and Sussex
University Hospitals.The decision to implement this guideline is at the discretion of the on-call critical care
consultant in conjunction with appropriate critical care medical/ nursing staff.

Date: Revised Aug 2018 Revision Date: Aug 2020 Authors: MT/IHL/TC/JN/BM/JW