Intracerebral Haemorrhage (ICH) (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

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: TAM subgroup of the 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