Intracerebral Haemorrhage (ICH) (Guidelines)

Warning

Audience

  • NHS Highland
  • Secondary Care only
  • Adults only

Haemorrhagic stroke confirmed on CT scan

Airway management

Consider early intubation in the following patients:

GCS <8
Worsening GCS
Seizures.

Swallow assessment + Involve stroke Team

07974123503.

Discuss surgical intervention with Neurosurgery

Surgical intervention

BP control as per surgical advice.

Not for surgical intervention

Follow guidance below for BP control, anticoagulation and imaging.

BP control

Intense BP control criteria:

Standard BP control criteria:

  • GCS >5, plus
  • Presentation with 6 hours of onset of symptoms, plus
  • SBP 150 to 220mmHg
  • GCS<5
  • Presentation >6 hours of onset of symptoms
  • SBP >220mmHg
  • Large hematoma
  • Structural or macrovascular cause
  • Advanced frailty

Target SBP:

  • 130 to 139mmHg within one hour
  • Avoid drop in SBP by >60mmHg

Target SBP:

  • ≤180mmHg.

BP control medications

1st line

  • IV labetalol → bolus or infusion (max dose 200mg/24 hrs)
  • Beta blocker infusion guidance: Critical Care Formulary.

2nd line

  • IV GTN → infusion (max 10mg/hr)

Aim to switch to oral medications within 72 hours.

BP + Neuro observations monitoring

  • BP monitoring every 15 minutes while on infusion.
  • Hourly for 6 hours (including neuro obs)
  • Then 4 to 6 hourly for 24 hours if stable (including neuro obs).

Reversal of anticoagulation

WARFARIN

Stop warfarin

Give IV Vitamin K
+
Start prothrombin complex precipitate (after consulting Haematology)

DOAC

Stop DOAC 

Factor Xa inhibitors

4-Factor prothrombin complex precipitate

Dabigatran

Idarucizumab.

Imaging

  1. Early CTA/MRA within 48 hours
    • 18 to 70 years old
    • Functionally independent
    • No history of cancer
    • Not on anticoagulants.
      NB: Early CTA/MRA is not indicated in patients above 45 with hypertension and the haemorrhage is in the basal ganglia, thalamus or posterior fossa.
  2. CTA/MRA in 3 months
    • In patients not meeting the criteria above where the probability of a macrovascular cause is felt to justify further investigation.

Further information for Health Care Professionals

Editorial Information

Last reviewed: 27/06/2024

Next review date: 01/05/2026

Author(s): Stroke Medicine.

Version: 1

Approved By: TAMSG of ADTC

Reviewer name(s): Dr W Rutherford, Consultant, Stroke/Acute Medicine).

Document Id: TAM639

References

National Clinical Guideline for Stroke in the United Kingdom and Ireland 2023