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Intracerebral hemorrhage

What's new

The European Stroke Organisation (ESO) and the European Association of Neurosurgical Societies (EANS) have updated their guidelines for the management of spontaneous intracerebral hemorrhage (ICH). In VKA-associated ICH, reversal should include prothrombin complex concentrate combined with IV vitamin K to normalize and stabilize the INR. For factor Xa inhibitor-associated ICH, prothrombin complex concentrate is suggested. Andexanet alfa can be considered within 12 hours of symptom onset and 15 hours of the last dose, or when anti-FXa activity is elevated. In dabigatran-associated ICH, immediate administration of idarucizumab is suggested. In patients with minor or moderate ICH (hematoma volume <30 mL), lowering systolic blood pressure to below 140 mmHg within 6 hours of symptom onset is recommended to reduce hematoma expansion. However, systolic pressure should not be reduced by more than 70 mmHg from baseline or lowered below 110 mmHg. The guidelines recommend against several isolated interventions, including intensive glucose control, primary antiseizure prophylaxis, and anti-inflammatory or neuroprotective agents such as corticosteroids, anakinra, and minocycline. .

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of intracerebral hemorrhage are prepared by our editorial team based on guidelines from the European Stroke Organisation (ESO/EANS 2025), the Neurocritical Care Society (NCS 2025,2020), the European Society of Cardiology (ESC 2024), the European Society of Hypertension (ESH 2023), the American Heart Association (AHA/ASA 2022), the Canadian Stroke Best Practice Recommendations ...
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Classification and risk stratification

Severity grading: as per AHA/ASA 2022 guidelines, obtain a baseline measurement of overall hemorrhage severity as part of the initial evaluation of patients with spontaneous ICH to provide an overall measure of clinical severity.
B
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Diagnostic investigations

Initial evaluation
As per EANS/ESO 2025 guidelines:
Consider using algorithms such as the DIAGRAM for targeted investigation of the cause of spontaneous ICH to improve the performance of prediction regarding the underlying cause, compared to standard care.
C
Consider limiting the use of the ICH score to providing prognostic information, rather than using it as the primary or sole method for predicting outcomes in adult patients with ICH, due to the risk of a self-fulfilling prophecy.
E
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  • Diagnostic imaging (CT/MRI)

  • Diagnostic imaging (CTA/MRA)

  • Diagnostic imaging (digital subtraction angiography)

Medical management

Setting of care: as per EANS/ESO 2025 guidelines, admit patients with ICH not requiring intensive care treatment to an organized stroke unit to reduce mortality and dependency.
B
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  • Prehospital care

  • Management of BP

  • Management of blood glucose

  • Management of coagulopathy (discontinuation of anticoagulation)

  • Management of coagulopathy (VKA-induced)

  • Management of coagulopathy (factor Xa inhibitor-induced)

  • Management of coagulopathy (direct thrombin inhibitor-induced)

  • Management of coagulopathy (heparin-induced)

  • Management of coagulopathy (antiplatelet-induced)

  • Management of coagulopathy (rFVIIa)

  • Management of coagulopathy (tranexamic acid)

  • Management of coagulopathy (ciraparantag)

  • Thromboprophylaxis

  • Management of ICP (monitoring)

  • Management of ICP (ventricular drainage)

  • Management of ICP (hyperosmolar therapy)

  • Management of ICP (corticosteroids)

  • Seizure prophylaxis

  • Management of seizures

  • Management of body temperature

  • Anti-inflammatory agents

  • Management of comorbidities

  • Withdrawal of care

Inpatient care

Clinical monitoring
As per AHA/ASA 2022 guidelines:
Obtain frequent neurological assessments (including GCS) by emergency department nurses in the early hyperacute phase of care to assess change in status, neurological examination, or level of consciousness in patients with spontaneous ICH.
B
Consider obtaining frequent neurological assessments in the ICU and stroke unit for up to 72 hours of admission to detect early neurological deterioration in patients with spontaneous ICH.
C
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  • Imaging monitoring

  • Prevention of inpatient complications

Nonpharmacologic interventions

Lifestyle modifications
As per AHA/ASA 2022 guidelines:
Consider offering lifestyle modifications to reduce BP in patients with spontaneous ICH.
C
Advise avoiding heavy alcohol consumption to reduce hypertension and risk of ICH in patients with spontaneous ICH.
B
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Surgical interventions

Indications for surgery, supratentorial hemorrhage: as per EANS/ESO 2025 guidelines, consider using a surgical approach for hematoma removal and prevention of secondary brain injury in adult patients with acute spontaneous supratentorial ICH to reduce the risk of death and dependence. Take into account factors such as hematoma location and volume, the patient's neurological condition, timing, method of intervention, and the surgeon's complication rate.
C
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  • Indications for surgery (cerebellar hemorrhage)

  • Indications for surgery (intraventricular hemorrhage)

Specific circumstances

Patients with AF
As per EANS/ESO 2025 guidelines:
Consider initiating DOAC treatment after ICH in patients with NVAF, as it may reduce the overall risk of major adverse cardiovascular events despite potentially increasing the risk of recurrent ICH. Evaluate the individual risk-benefit profile carefully.
E
Consider performing LAA occlusion to reduce thromboembolic events in adult patients with prior ICH and NVAF who are unsuitable for long-term oral anticoagulation therapy, such as patients with imaging or pathological evidence of cerebral amyloid angiopathy. Encourage enrollment of these patients in RCTs.
E
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  • Patients with concomitant VTE

Patient education

Caregiver counseling
As per AHA/ASA 2022 guidelines:
Consider providing psychosocial education for the caregiver to increase patients' activity level and participation and/or QoL.
C
Consider providing practical support and training for the caregiver to improve patients' standing balance.
C
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Preventative measures

Primary prevention: as per AHA/ASA 2022 guidelines, consider incorporating any available MRI results demonstrating cerebral microbleed burden or cortical superficial siderosis to inform shared decision-making about stroke prevention treatment plans when considering primary prevention of ICH.
C
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  • Secondary prevention

Follow-up and surveillance

Stroke rehabilitation: as per AHA/ASA 2022 guidelines, offer multidisciplinary rehabilitation including regular team meetings and discharge planning to improve functional outcomes and reduce morbidity and mortality in patients with spontaneous ICH.
A
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  • Management of neurobehavioral complications

  • Follow-up imaging

  • Long-term medical therapy (resumption of antithrombotics)

  • Long-term medical therapy (management of BP)

  • Long-term medical therapy (statin therapy)

Quality improvement

Care bundles: as per EANS/ESO 2025 guidelines, implement a care bundle to reduce death or dependence in adult patients with acute spontaneous ICH.
B
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  • Public health measures