Intracerebral haemorrhage

Manage patients with an intracerebral haemorrhage in hospital.

Some patients with an intracerebral haemorrhage have a bleeding tendency, usually due to drugs such as anticoagulants. As growth of the haematoma is associated with a worse outcome, reverse the bleeding diathesis if possible. If the patient has coagulation factor deficiency or severe thrombocytopenia, give factor replacement therapy or platelets. If the patient is on warfarin therapy, reverse this urgently with a combination of prothrombin complex concentrate, fresh frozen plasma and vitamin K—seek advice from a haematologist. Also seek advice from a haematologist if the patient is taking a direct-acting oral anticoagulant (DOAC).

Urgently lower the blood pressure in acute intracerebral haemorrhage, to reduce haematoma expansion—see advice. It is safe to aim to lower systolic blood pressure to about 140 mmHg.

If a patient is immobilised by the intracerebral haemorrhage, use an intermittent pneumatic compression device as prophylaxis for deep vein thrombosis. Common practice is to start low molecular weight heparin (eg enoxaparin, dalteparin) 48 hours after the haemorrhage—see dosing information.

Surgical evacuation of the haematoma can be considered, but is an expert decision that must take into account patient comorbidity and preferences. In general, large supratentorial haematomas have a high risk of death or major disability and should not be evacuated. In contrast, decompression of cerebellar haematomas may have benefit. Seek local advice from stroke specialists and neurosurgeons.

Raised blood pressure is the main risk factor for recurring intracerebral haemorrhage. Aggressively manage blood pressure in all patients after intracerebral haemorrhage, aiming to reduce the systolic blood pressure to 120 mmHg or lower (as tolerated)—see treatment advice. Treatment continues lifelong.

Using antiplatelet and anticoagulant drugs after haemorrhagic stroke is controversial. Seek expert advice.