Blood in the Brain: Updated ICH Guidelines

Drew Kalnow, DO and Andy Little, DO

on Spotify

The summary below is from an episode of ERcast: Clinical Perspectives

Spontaneous intracerebral hemorrhage is a high-mortality stroke subtype where delayed recognition and sloppy blood pressure control worsen outcomes. Non-contrast head CT remains the ED test of choice, and the 2022 Stroke guidelines push early, controlled antihypertensive treatment plus targeted reversal of anticoagulants.

Updated Intracerebral Hemorrhage Management

High-risk clinical clues: Thunderclap headache, new seizure without a seizure history, focal deficit during the seizure, and severe hypertension should all raise concern for ICH, even when the presentation does not score impressively on stroke tools.
Preferred initial imaging: Non-contrast head CT is the first-line ED test and is nearly 100% sensitive for acute blood within 6 hours, making it the key rule-in study when ICH is on the table.
CTA and LP nuance: A normal non-contrast CT does not end the workup when the story is worrisome; CTA and sometimes lumbar puncture still matter in select patients. We get into that diagnostic fork in the episode.
Controlled blood pressure target: ICH blood pressure management is about smooth afterload reduction, not a crash; start treatment within 2 hours of diagnosis and aim for SBP 140 mm Hg within 1 hour of initiation.
Safe systolic range: For mild to moderate ICH, the practical target range is SBP 130 to 150 mm Hg, while pushing below 130 mm Hg is associated with harm rather than better neurologic outcomes.
Antithrombotic reversal priorities: Warfarin reversal hinges on 4-factor PCC plus vitamin K, DOACs now have specific antidotes, and platelet transfusion for aspirin or clopidogrel is generally avoided unless surgery is planned.

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References:

Greenberg SM, et al. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2022;53(7):e282-e361. PMID: 35579034
Hill DH, & Muir KW. INTERACT-2: should blood pressure be aggressively lowered acutely after intracerebral hemorrhage? Stroke. 2013 Oct;44(10):2951-2. PMID: 23988644
Qureshi AI, et al. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med. 2016 Sept 15;375(11):1033-43. PMID: 27276234

Faculty

Drew Kalnow, DO
Dr. Drew Kalnow is an emergency medicine physician and educator based in Columbus, Ohio. He completed his emergency medicine training at OhioHealth Doctors Hospital Emergency Medicine Residency. Dr. Kalnow is passionate about advancing emergency medicine through high-quality education, with a particular focus on simulation, learning theory, and innovative teaching.
Andy Little, DO
Dr. Andy Little is an emergency medicine physician and educator. He earned his medical degree from the Ohio University Heritage College of Osteopathic Medicine and completed his emergency medicine residency at OhioHealth Doctors Hospital Emergency Medicine Residency, where he served as Chief Resident. He has received multiple national awards, including recognition from the American Osteopathic Association, American College of Osteopathic Emergency Physicians, and Emergency Medicine Residents' Association.