Template:ICH Treatment

Elevating head of bed

  • 30 degree elevation will help decrease ICP[1]

Seizure Prophylaxis and Treatment

  • Prophylactic antiepileptics not recommended[2]
  • Continuous EEG monitoring probably indicated in ICH patients with depressed mental status that is out of proportion fo degree of brain injury[3]
  • Antiepileptics indicated for clinical seizures or seizures on EEG in patients with altered mental status[4]

Blood Pressure

  • Rapid SBP lowering <140 has been advocated with early research showing improved functional outcome[5], but more recent work has found no difference between SBP <140 and <180[6]
  • SBP >200 or MAP >150
    • Consider aggressive reduction w/ continuous IV infusion
  • SBP >180 or MAP >130 and evidence or suspicion of elevated ICP
    • Consider reducing BP using intermittent or continuous IV meds to keep CPP >60-80
  • SBP >180 or MAP >130 and NO evidence or suspicion of elevated ICP
    • Consider modest reduction of BP (e.g. MAP of 110 or target BP of 160/90)


  • Nicardipine in ICH: Start at 5mg/hr, increase 2.5mg q5min until the target blood pressure is achieved and then immediately titrate down to maintenance infusion of 3mg/hr.
  • Labetalol in ICH: 20mg bolus over 1-2 minutes, repeat q3-5 mins until target blood pressure is achieved and then start an infusion of 1-8mg/min.

Reverse coagulopathy

Antiplatelet Reversal

Includes aspirin, prasugrel, clopidogrel

  • Consider desmopressin (0.3mcg/kg)
  • Platelet transfusion
    • No known thrombocytopenia: increases mortality; do NOT give[8]
    • Known or diagnosed thrombocytopenia: consider if platelets <50,000
      • Some hematologists and neurosurgeons recommend for <100,000, despite lack of evidence for improved outcomes
  • http://stroke.ahajournals.org/content/38/6/2001.full
  • AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage 2015
  • AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage 2015
  • AHA/ASA Guidelines for the Management of Spontaneous Intracerebral Hemorrhage 2015
  • Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013; 368:2355-2365.
  • Qureshi AI, Palesch YY, Barsan WG, et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. 2016; 1-11. [Epub ahead of print].
  • Crash-3 Trial
  • (PATCH trial)