A clinician-minded learning console for spontaneous intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage. Stop expansion, reverse coagulopathy, smooth the pressure, secure the aneurysm, and protect recovery without nihilism.
Hemorrhage is not one disease. ICH, IVH, aSAH, hemorrhagic transformation, AVM rupture, dural fistula, venous thrombosis, and tumor bleeding all share early signs — and diverge sharply on management.
Thunderclap headache ("worst of life"), vomiting, decreased consciousness, seizure at onset, severe hypertension, neck stiffness, gaze deviation, sudden focal deficit, or rapid decline — especially in patients on anticoagulants — demands emergency neuroimaging within minutes and concurrent stroke + neurosurgical activation. Always check fingerstick glucose. Document anticoagulant + last dose + renal function before any other labs come back.
Deep (basal ganglia, thalamus, pons, cerebellum) → hypertensive arteriolosclerosis. Lobar in older adults → cerebral amyloid angiopathy (Boston Criteria 2.0). Always suspect anticoagulant-associated, vascular lesion, tumor, or drug-induced bleeding.
Worst-headache-of-life onset in seconds, meningismus, photophobia, vomiting, syncope, altered mental status. ~10–15% die before reaching hospital. NCCT within 6 h is >99% sensitive when interpreted by a radiologist; LP only if CT negative and clinical concern persists.
Blood in ventricles can obstruct CSF flow → acute obstructive hydrocephalus. Falling GCS, posturing, pupil changes, or ventricular dilatation on CT trigger urgent EVD discussion. Score IVH burden with the Graeb scale or modified Graeb.
Anticoagulants (warfarin, DOACs, heparin), antiplatelets, thrombolytics, and severe thrombocytopenia (<100K) can turn a contained bleed into a 50% expansion. Reversal is parallel — not sequential to BP control.
For decades, no acute ICH intervention improved functional outcome. INTERACT3 (Anderson et al, 7,036 patients across 121 hospitals) finally did — by bundling four simple interventions delivered fast and together.
Each step is feasible in any hospital with imaging and basic ICU. The benefit comes from doing all four early and together, not from any one in isolation.
Think in parallel — diagnosis, BP control, anticoagulant reversal, neurosurgical triage, ICU, and family communication all run simultaneously. Sequential thinking loses brain.
ABCs, glucose, GCS, NIHSS, focused exam. Document last-known-well, anticoagulant + dose + timing, baseline mRS, family contact. Activate stroke team.
Noncontrast CT confirms blood. CTA identifies aneurysm, AVM, dural AVF, spot sign (predicts expansion). MRI/MRV if etiology unclear or venous thrombosis suspected.
Stop antithrombotics. Specific reversal per agent (see drug cards). Target SBP ≤140 within 1 hour. Use titratable IV agents (nicardipine, clevidipine, labetalol).
Cerebellar >3 cm or ≥15 mL with deterioration → emergent surgery. IVH + hydrocephalus → EVD. Lobar 30–80 mL with GCS 5–14 → consider ENRICH-eligible MIPS.
ICP, fever, glucose, dysphagia screen, IPC immediately + pharmacologic VTE proph 24–48 h after stable hemostasis, seizure treatment (not prophylaxis), DCI surveillance for SAH, rehab planning.
Six high-yield decision frames. Click each to reveal the question, the action, and the trap. Use the reversal cards below for exact dosing and the surgery cards for triage thresholds.
AHA/ASA 2022 emphasizes smooth, sustained BP control with limited variability. For mild-to-moderate ICH presenting with SBP 150–220, lowering toward 140 mmHg with maintenance 130–150 is reasonable; intensive lowering below 130 may be harmful. Initiate within 2 hours, reach target within 1 hour.
Identify the agent → check timing, renal function, and last dose → choose the targeted reversal. Reversal happens in parallel with BP control, not after it.
UFH: 1 mg per 100 units of heparin given in last 2–3 h (max 50 mg). LMWH: 1 mg per 1 mg enoxaparin if <8 h (~60% reversal); 0.5 mg per 1 mg if >8 h. Slow IV push to avoid hypotension and anaphylactoid reactions.
PATCH trial (Lancet 2016): platelet transfusion in antiplatelet-associated ICH worsened outcomes. AHA/ASA 2022 recommends against routine platelet transfusion. Exception: emergency neurosurgery requiring procedural hemostasis. Desmopressin (0.4 µg/kg) is sometimes used but evidence is weak.
If ICH within 24 h of IV thrombolytic: stop infusion immediately. Cryoprecipitate 10 units (replenishes fibrinogen; target >150–200 mg/dL). Tranexamic acid 1 g IV is sometimes added. Platelet transfusion only if <100K. Neurosurgery consult for evacuation/EVD.
TICH-2 (Lancet 2018) & STOP-AUST (Stroke 2020) were neutral. AHA/ASA 2022: TXA effectiveness for functional outcome in spontaneous ICH (with or without spot sign) is not well established. Not part of the INTERACT3 bundle. Reserve for trauma-associated bleeding contexts (CRASH-3).
Most ICH is medically managed. But three scenarios are time-critical surgical decisions: cerebellar hemorrhage with mass effect, IVH with obstructive hydrocephalus, and ENRICH-eligible lobar supratentorial ICH.
The posterior fossa has no room. Brainstem compression and obstructive hydrocephalus develop fast and can be fatal within hours.
Up to 40% of ICH patients have IVH; obstructive hydrocephalus is the immediate threat. EVD diverts CSF; intraventricular thrombolytic accelerates clearance.
ENRICH (NEJM 2024, Pradilla et al): minimally invasive parafascicular surgery (MIPS) within 24 h improved 6-month uw-mRS (0.458 vs 0.374). Benefit driven by lobar group; basal ganglia arm stopped for futility.
Five components, 0–6 points. Validated for 30-day mortality. Use it to communicate severity — not as the sole basis for limiting care (AHA/ASA 2022 explicit warning against early DNAR or care-withdrawal anchored on ICH Score alone).
| Component | Finding | Points |
|---|---|---|
| GCS | 3–4 | 2 |
| GCS | 5–12 | 1 |
| GCS | 13–15 | 0 |
| Age | ≥80 years | 1 |
| Age | <80 years | 0 |
| ICH volume | ≥30 mL (use ABC/2 method) | 1 |
| ICH volume | <30 mL | 0 |
| IVH | Present | 1 |
| IVH | Absent | 0 |
| Infratentorial | Origin (cerebellum, brainstem) | 1 |
| Infratentorial | Supratentorial | 0 |
AHA/ASA 2022 explicitly cautions against using ICH Score (or any severity scale) as the sole basis to limit life-sustaining treatment. Aggressive early care plus 24–72 h of observation is recommended before goals-of-care discussions about DNAR, withdrawal, or comfort transitions, except where prior advance directives or clearly devastating injuries dictate otherwise.
aSAH is not a one-event illness. Secure the aneurysm ≤24 h to prevent rebleeding, then navigate hydrocephalus, delayed cerebral ischemia (DCI), seizures, hyponatremia, cardiac stunning, and rehabilitation. Mortality remains ~30% (10–15% pre-hospital).
| Grade | Findings |
|---|---|
| I | Asymptomatic / mild headache, slight nuchal rigidity |
| II | Moderate-severe headache, meningismus, no focal deficit (except CN palsy) |
| III | Drowsy / confused, mild focal deficit |
| IV | Stupor, moderate-severe hemiparesis |
| V | Coma, decerebrate posturing, moribund |
| Grade | GCS · Motor Deficit |
|---|---|
| I | GCS 15 · no deficit |
| II | GCS 13–14 · no deficit |
| III | GCS 13–14 · with focal deficit |
| IV | GCS 7–12 · with/without deficit |
| V | GCS 3–6 · with/without deficit |
| Grade | CT Findings · DCI Risk |
|---|---|
| 0 | No SAH, no IVH · 0% |
| 1 | Thin SAH, no IVH · 6–24% |
| 2 | Thin SAH + IVH · 15–33% |
| 3 | Thick SAH (≥1 mm), no IVH · 33–35% |
| 4 | Thick SAH + IVH · 34–40% |
| Level | MRI / Hemorrhagic Findings |
|---|---|
| Definite | Pathologic confirmation |
| Probable | ≥2 lobar bleeds OR 1 lobar + cSS, age ≥50 |
| Possible | 1 lobar bleed OR cSS, age ≥50 |
| Note | Now includes WMH-MS, severe MRI-visible PVS, & cortical superficial siderosis (cSS) |
15–20% before aneurysm secured; mortality ~70%. Secure ≤24 h. SBP target <160 (some advocate <140) before securing. Brief antifibrinolytic (TXA or aminocaproic acid) ≤72 h is reasonable per AHA/ASA 2023 if securing is delayed.
~20% develop acute obstructive hydrocephalus. EVD for GCS deterioration with ventricular dilation. Persistent CSF dependence in ~10–20% requires VP shunt conversion. Lumbar drain is alternative once aneurysm secured.
Up to 30% develop delayed cerebral ischemia. Surveillance: serial neuro exam, TCDs (MCA velocities >200 cm/sec or Lindegaard ratio >3), CTA/CTP, or DSA. Treatment: induced hypertension (no longer "triple-H"), endovascular angioplasty / intra-arterial verapamil.
~30% of patients. Cerebral salt wasting (volume-depleted, high urine Na, low CVP) → replace volume + Na (3% saline). SIADH (euvolemic) → fluid restriction is risky in SAH (worsens DCI). Both: maintain euvolemia, target Na 135–145.
Neurogenic stunned myocardium ("Takotsubo-like"): troponin elevation, regional wall motion abnormalities, pulmonary edema, ECG changes. Self-limited (days–weeks). Avoid β-blockers if hypotensive. ECMO bridge in extreme cases.
~6–18%, especially with cortical involvement. Don't routinely prophylax. Treat clinical or electrographic seizures. Continuous EEG for unexplained altered mentation, especially after securing. Levetiracetam preferred (fewer interactions, no enzyme induction).
Pick a presentation. The pathway updates with the immediate moves, the dose, the trap, and the "do-not-miss" pearl.
NCCT confirms blood. Document last antithrombotic dose, renal function, INR, platelets. Glucose is non-negotiable.
SBP ≤140, glucose 110–180, fever <37.5, anticoagulant reversal. Together, fast — that's where the OR 0.86 lives.
Cerebellar >3 cm or 15 mL → OR. IVH + hydrocephalus → EVD. Lobar 30–80 mL with GCS 5–14 → ENRICH-eligible.
Aggressive 24–72 h then re-evaluate. Severity scores guide communication, not the decision to withdraw.
Location and host context shape recurrence prevention, antithrombotic decisions, family counseling, and follow-up imaging. The discharge plan should answer why this happened.
Deep locations: basal ganglia, thalamus, pons, cerebellum. Charcot-Bouchard microaneurysms of small perforators. BP control (target <130/80) is the single most-effective recurrence intervention.
Lobar location, age ≥55, often recurrent. Cortical superficial siderosis, lobar microbleeds, white matter hyperintensities. Boston Criteria 2.0 (2022) for diagnosis. Restarting antithrombotics is delicate — shared decision-making essential.
AVM (Spetzler-Martin grade I–V predicts surgical risk), aneurysm, cavernoma, dural AVF, moyamoya, dissection. CTA/MRA is screening; DSA remains gold standard when CTA is negative but suspicion remains high.
Anticoagulants (warfarin, DOACs, heparin), antiplatelets, thrombolytics, sympathomimetics (cocaine, amphetamines, MDMA, decongestants), severe thrombocytopenia. Reversal urgency depends on agent + timing.
Hemorrhagic venous infarct pattern, headache, seizures, papilledema. Pregnancy/postpartum, OCPs, malignancy, infection, thrombophilia. MRV or CTV diagnostic. Anticoagulation is treatment despite hemorrhage.
Hemorrhagic mets (melanoma, RCC, thyroid, choriocarcinoma), high-grade glioma, pituitary apoplexy, vasculitis (PACNS, RCVS), endocarditis with mycotic aneurysm. Look for atypical edema, multiple lesions, or contrast enhancement on follow-up MRI.
The 2024 AHA/ASA ICH performance and quality measures translate the 2022 guideline into measurable hospital behavior. Good clinicians use systems: triage, transfer, stroke certification, and audit loops.
Cover prehospital to posthospital care: time-to-CT, BP control, anticoagulant reversal, dysphagia screen, VTE prophylaxis, smoking cessation, statins, follow-up imaging, rehab assessment, palliative care, caregiver training.
15 PMs + 5 QMsComprehensive Stroke Centers and Thrombectomy-capable centers should accept ICH transfers requiring neurocritical care, neurosurgical, or endovascular expertise. Standardized transfer agreements reduce time to definitive care.
CSC tierGet With The Guidelines–Stroke is the U.S. registry tracking ICH care: door-to-CT, BP control timing, reversal compliance, rehab assessment, discharge prevention, 90-day mRS. Drives continuous improvement.
U.S. standardPrimary Stroke Center, Thrombectomy-Capable, and Comprehensive Stroke Center certification. Each carries standardized performance measures and regular data submission requirements aligned with bedside workflow.
3 tiersAVERT trial (Lancet 2015): very early aggressive mobilization (<24 h) was harmful in stroke. AHA/ASA 2022: out-of-bed activity should not begin within first 24 h after ICH. Functional task training can follow once stable. PT/OT/SLP assessment by day 2–3.
Not <24hAHA/ASA 2022 highlights caregiver education, psychosocial support, depression screening (PHQ-9), and practical training as core to discharge planning. Burden falls disproportionately on family — formal support reduces caregiver depression and re-hospitalization.
Discharge coreTwelve high-yield questions across recognition, the INTERACT3 bundle, anticoagulant reversal, ICH Score, surgical triage, aSAH grading, and complications. Streak counter, badges, immediate teaching pearl after every answer.
Per AHA/ASA 2022, what is the recommended SBP target in mild-to-moderate spontaneous ICH presenting with SBP 150–220 mmHg?
This tool summarizes, simplifies, and teaches — it does not reproduce full guidelines. Always defer to current institutional protocols and the latest published versions before clinical decisions.
This Didactic Med educational tool is intended exclusively for the continuing education of healthcare professionals (physicians, residents, advanced practice providers, nurses, paramedics, and medical students).
Hemorrhagic stroke (ICH and aSAH) is a medical emergency with high acute mortality. This tool is not a clinical practice guideline, emergency protocol, neurosurgical triage rule, medication order set, or substitute for evaluation by qualified clinicians. Real-world treatment decisions require immediate local stroke + neurosurgical + neurocritical-care activation, current institutional protocols, imaging interpretation, complete anticoagulant + antiplatelet history, current medication labeling, laboratory review, patient-specific risk-benefit assessment, and shared decision-making with patients and families when feasible.
Do not use this tool as the sole basis for diagnosis, blood pressure management, anticoagulation reversal, aneurysm treatment selection, EVD placement, surgical evacuation, transfer decisions, withdrawal or limitation of life-sustaining treatment, discharge, insurance, or legal decisions. Evidence and guidelines evolve continuously — always verify current recommendations before clinical application.
In any suspected stroke, thunderclap headache, or sudden neurological emergency, call emergency services immediately and activate stroke + neurosurgical pathways per local institutional protocol.
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