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Spontaneous intracerebral hemorrhage (ICH)
In intracerebral hemorrhage the haematoma keeps growing in the first hours, so treatment is a race to stop expansion: controlled blood-pressure lowering, immediate reversal of anticoagulants, and spotting who needs surgery.
Why it matters in the exam
Questions present a sudden focal deficit with headache, vomiting and falling consciousness, and CT shows blood. The decisions tested are the blood-pressure target, which agent reverses which anticoagulant, when a cerebellar bleed is operated on, and which treatments are not recommended (routine seizure prophylaxis, platelet transfusion for a patient on aspirin). Location hints at the cause: deep means hypertension, lobar in an older patient means amyloid angiopathy.
Key points
- A deep bleed is usually hypertensive; a lobar bleed in an older patient suggests amyloid angiopathy.
- The haematoma grows in the first hours, so lower systolic pressure to 140 mmHg and not below 130.
- Reverse anticoagulants at once: PCC and vitamin K for warfarin, idarucizumab for dabigatran, andexanet or PCC for Xa inhibitors.
- A cerebellar bleed over 3 cm, brainstem compression or hydrocephalus are indications for surgery or drainage.
- No routine seizure prophylaxis and no routine platelet transfusion for patients on antiplatelets.
Summary table
| Topic | Rule | Note |
|---|---|---|
| Cause by location | Basal ganglia, thalamus, pons and cerebellum — chronic hypertension; lobar bleed in an older patient — cerebral amyloid angiopathy (CAA) | In the young or in an unusual site look for an arteriovenous malformation, tumour or drugs |
| Blood pressure | With systolic pressure 150 to 220 mmHg — target 140, without falling below 130 | Gradual, sustained lowering; sharp swings are harmful |
| Anticoagulant reversal | Warfarin — 4-factor PCC plus intravenous vitamin K 10 mg; dabigatran — idarucizumab 5 g; factor Xa inhibitors — andexanet alfa or PCC | Start at once, before full laboratory results |
| Surgery | Cerebellar bleed over 3 cm, brainstem compression or hydrocephalus — surgical evacuation | Hydrocephalus alone — external ventricular drain (EVD) |
| ICH score | GCS 3 to 4 (2) or 5 to 12 (1), volume 30 mL or more (1), intraventricular blood (1), infratentorial site (1), age 80 or more (1) | Volume is estimated with the ABC/2 formula |
| What not to do | Routine seizure prophylaxis, platelet transfusion for a patient on an antiplatelet who is not having surgery, steroids | VTE prevention: intermittent pneumatic compression from day one |
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Sources
- AHA/ASA Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage, 2022 — Blood pressure, reversal of anticoagulation and surgical management
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.