Critical Alerts

• Time-critical diagnosis: CT head without contrast immediately
• Blood pressure management is crucial: Aggressive lowering for ICH (target SBP <140)
• Reverse anticoagulation urgently: Every minute counts for hematoma expansion
• SAH may have negative CT: LP required if high suspicion and CT normal
• Herniation signs require immediate action: Osmotherapy and neurosurgery
• Airway protection: GCS ≤8 requires intubation

Key Diagnostics

Emergency Treatments

Overview

Intracranial haemorrhage (ICH) refers to bleeding within the cranial vault, including the brain parenchyma, subarachnoid space, subdural space, or epidural space. It is a medical emergency with high mortality and morbidity requiring rapid diagnosis, blood pressure control, reversal of anticoagulation, and neurosurgical evaluation.

Classification

By Location:

Intracerebral Hemorrhage by Location:

Epidemiology

• ICH incidence: 10-30 per 100,000/year
• SAH incidence: 6-9 per 100,000/year
• ICH mortality: 30-50% at 30 days
• SAH mortality: 25-50% overall
• Age: Increases with age; median age 65-70 for ICH
• Anticoagulation-related: 12-20% of all ICH (increasing)

Etiology

Intracerebral Hemorrhage:

Subarachnoid Hemorrhage:

Immediate Life Threats

Poor Prognostic Indicators (ICH)

• Large hematoma volume (>30 mL supratentorial, >15 mL infratentorial)
• Intraventricular extension
• Low GCS at presentation
• Age >80
• Anticoagulation
• Infratentorial location
• Spot sign on CTA (ongoing bleeding)

Other Causes of Sudden Severe Headache

Imaging

CT Head Non-Contrast (First-Line):

• Immediately abnormal for acute hemorrhage
• Identifies location, volume, mass effect, hydrocephalus
• Sensitivity for SAH: 95-100% in first 6 hours; decreases with time

CT Angiography (CTA):

MRI:

• Better for underlying lesions, cavernomas
• Gradient echo/SWI for microbleeds (CAA)
• Not emergent for diagnosis of acute hemorrhage

Lumbar Puncture (SAH):

• Indicated if CT negative but high clinical suspicion for SAH
• Wait 6-12 hours after symptom onset for xanthochromia to develop
• Findings: Elevated RBCs (non-clearing), xanthochromia (yellow supernatant)

Cerebral Angiography (DSA):

• Gold standard for aneurysm characterization
• May be needed if CTA inconclusive
• Performed by neurosurgery/neurointerventional

Laboratory Studies

ICH Volume Estimation (ABC/2 Method)

Volume (mL) = (A × B × C) / 2

• A = largest diameter in cm
• B = perpendicular to A on same slice
• C = number of slices with hemorrhage × slice thickness

ICU Admission

• All ICH patients require ICU admission
• Dedicated Neurological ICU if available
• Frequent neurological checks (q1h)
• Continuous blood pressure monitoring

Neurosurgery Consultation

• Immediate for all intracranial hemorrhage
• Surgical decision-making
• ICP monitoring placement if indicated
• EVD for hydrocephalus

Transfer Considerations

• Transfer to comprehensive stroke center if surgery/intervention needed
• Time-critical; do not delay
• Stabilize before transfer (intubation, BP control, reversal started)

Goals of Care

• Early goals of care discussion
• Avoid early withdrawal of care (prognostication unreliable in first 24-48h)

For Families

• "Your loved one has bleeding in the brain, which is very serious."
• "We are working to stop the bleeding from getting bigger and to protect the brain."
• "They will need intensive care and possibly surgery."
• "The next few days are critical for understanding how they will recover."

Long-Term (Survivors)

• Blood pressure control is critical for prevention
• Medication compliance
• Follow-up imaging
• Rehabilitation services
• Driving restrictions

Prevention for At-Risk Patients

• Blood pressure control (most important)
• Avoid excessive anticoagulation
• Avoid cocaine and amphetamines
• Recognize warning signs

Anticoagulated Patients

• Highest priority: STOP and REVERSE anticoagulation immediately
• Higher mortality without reversal
• Do not wait for repeat imaging to start reversal

Elderly

• Higher prevalence of CAA
• More likely to be on anticoagulation
• Higher mortality
• Frailty impacts prognosis and surgical candidacy

Young Patients with ICH

• More likely to have underlying vascular lesion (AVM, aneurysm)
• More aggressive imaging workup
• Better recovery potential

Pregnancy

• Eclampsia as cause of ICH
• SAH risk increases in pregnancy
• Multidisciplinary management
• Consider delivery for term or near-term

Warfarin Users

• 7× increased risk of ICH
• Rapid reversal essential
• PCC preferred over FFP

Performance Indicators

Documentation Requirements

• Time of symptom onset
• Initial and serial GCS
• Blood pressure and management
• Anticoagulation status and reversal
• CT findings including volume
• Neurosurgery consultation
• Goals of care discussion

Diagnostic Pearls

• Thunderclap headache = SAH until proven otherwise: LP if CT negative
• CT negative doesn't rule out SAH >6 hours: Need LP
• Spot sign on CTA: Active bleeding; predicts expansion
• Lobar hemorrhage in elderly: Think CAA
• Young patient + lobar ICH: Always look for underlying lesion
• Sentinel headache: May precede major SAH by days to weeks

Treatment Pearls

• Aggressive BP control for ICH: SBP <140 is safe
• Reverse anticoagulation immediately: PCC not FFP
• Careful with fluids: Avoid overload
• Mannitol needs good perfusion: Avoid if hypotensive
• Nimodipine for SAH: Oral, not IV (causes hypotension)
• Don't withdraw care early: Wait 48 hours minimum for prognosis

Disposition Pearls

• All ICH to ICU: No exceptions
• Cerebellar hemorrhage: Low threshold for surgery (can herniate rapidly)
• Goals of care early but not too early: Initial 24-48h prognosis unreliable
• Rehabilitation planning: Start early for survivors