ICH: lower SBP to ~140 mmHg (avoid < 130) within 2 h, reverse anticoagulants immediately, treat hydrocephalus, and avoid prophylactic antiseizure drugs. Aneurysmal SAH: nimodipine, early aneurysm securing, euvolaemia, and vigilance for rebleeding, hydrocephalus and delayed cerebral ischaemia.
At the bedside
Timed steps- 1
BP
ICHSBP 150-220: target 140 mmHg (range 130-150) started within 2 h and reached within 1 h of starting; avoid drops > 70 mmHg and SBP < 130. Smooth control with labetalol or nicardipine.
- 2
Reverse
ICHWarfarin: 4-factor PCC (dose by INR) + vitamin K 10 mg IV. Dabigatran: idarucizumab 5 g. Factor Xa inhibitors: andexanet alfa or 4F-PCC 50 units/kg. Heparin: protamine. Platelet transfusion is not recommended for antiplatelet-associated ICH without surgery.
- 3
Neurosurgery
ICHCerebellar haemorrhage > 15 mL with deterioration, brainstem compression or hydrocephalus: evacuation. IVH with hydrocephalus: EVD.
- 4
Supportive
ICHGlucose 80-180 (avoid hypo), normothermia, intermittent pneumatic compression from day 1; no prophylactic antiseizure drugs; no steroids.
- 5
Diagnose and grade
SAHThunderclap headache: CT within 6 h is highly sensitive; otherwise LP for xanthochromia. CTA for aneurysm. Grade with WFNS or Hunt-Hess.
- 6
Before securing
SAHTreat BP (commonly SBP < 160), reverse anticoagulation, nimodipine 60 mg 4-hourly for 21 days, EVD for hydrocephalus, secure aneurysm (coil or clip) as early as possible, ideally < 24 h.
- 7
Days 3-14
SAHEuvolaemia (no prophylactic hypervolaemia), Na+ monitoring (SIADH vs cerebral salt wasting), TCD or clinical monitoring for delayed cerebral ischaemia; DCI: induced hypertension, then endovascular therapy.
WFNS grade for SAH
| Grade | GCS | Motor deficit |
|---|---|---|
| I | 15 | Absent |
| II | 13-14 | Absent |
| III | 13-14 | Present |
| IV | 7-12 | Present or absent |
| V | 3-6 | Present or absent |
Higher grades predict worse outcome; grade should be re-assessed after resuscitation and EVD.
References
- 1
- 2
Spontaneous ICH
Step 1 of ~5
SBP target 140 (avoid < 130) within 2 h
Based on Greenberg SM, Ziai WC, Cordonnier C, et al. Educational use; follow local protocol.
Evidence
- AHA/ASA ICH 2022: BP target 140 for SBP 150-220; reversal algorithms; avoid platelet transfusion for antiplatelet ICH (PATCH).
- AHA/ASA SAH 2023: nimodipine, early securing, against prophylactic hypervolaemia and TXA.
Controversies
- Minimally invasive evacuation for lobar ICH (ENRICH 2024) is promising but not widely available.
🇮🇳 India notes
- Hypertensive ICH is far commoner in India than in the West and occurs at a younger age; neurosurgical and coiling access vary widely; andexanet is rarely available, so 4F-PCC is used.
References
- 1
- 2
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