It is critical to master the management of the patient with intracerebral hemorrhage (ICH) because hematoma expansion typically occurs in the first few hours after the bleed starts, and hematoma volume is the most important predictor of early deterioration.¹ A self-fulfilling prognostic pessimism exists when it comes to ICH, and this pessimism sometimes leads to less-than-optimal care in patients who otherwise might have had a reasonably good outcome if managed aggressively.

Despite the poor prognosis of these patients overall, there is some evidence to suggest that early aggressive medical management may improve outcomes.² As such, the skill with which you manage your emergency department ICH patients matters. In this golden hour, you have a chance to prevent hematoma expansion, stabilize intracerebral perfusion, and give your patient the best chance of survival with a favorable neurological recovery.

Five major considerations in the medical management of ICH should guide your management: blood pressure (BP), coagulation, glucose, temperature, and intracranial pressure (ICP) control.

Blood Pressure Management

For those ICH patients with Glasgow Coma Scale (GCS) scores >7, the current recommendation to lower BP to 140/80 is unlikely to be harmful but may be minimally beneficial. However, two recent trials have failed to definitively show benefit. The INTERACT2 trial was a randomized, controlled trial (RCT) of 2,839 patients with spontaneous ICH and elevated systolic BP who were randomized to intensive treatment (<140) versus guideline-recommended therapy (<180).

Outcomes were modified Rankin score of 3 to 6 (death and major disability) at 90 days. The researchers found no significant difference in primary outcomes.³ The ATACH-II RCT compared a lower systolic BP target of 110 to 139 mm Hg with a standard target of 140 to 179 in 1,000 patients using IV labetalol, diltiazem, or urapidil. Patients were eligible if they had at least one episode of systolic BP >180 mmHg between symptom onset and 4.5 hours. The trial was stopped early for futility, with no difference in the primary outcome of death or disability (intensive treatment group 38.7 percent versus control 37.7 percent).⁴ While the target BP in ICH requires more study, there is no question that hypotension should be avoided at all costs in patients with ICH.

Platelet Transfusions

All patients with a platelet count <50,000 in the setting of ICH require platelet transfusion. However, most hematologists and neurosurgeons recommend platelet transfusion for ICH with a platelet count <100,000 despite the lack of evidence for improved outcomes, especially when the patient requires emergency surgery.