Treatment of intracerebral hemorrhage: From specific interventions to bundles of care

Adrian R. Parry-Jones, Tom J. Moullaali, Wendy C. Ziai

Research output: Contribution to journalReview articlepeer-review


Intracerebral hemorrhage (ICH) represents a major, global, unmet health need with few treatments. A significant minority of ICH patients present taking an anticoagulant; both vitamin-K antagonists and increasingly direct oral anticoagulants. Anticoagulants are associated with an increased risk of hematoma expansion, and rapid reversal reduces this risk and may improve outcome. Vitamin-K antagonists are reversed with prothrombin complex concentrate, dabigatran with idarucizumab, and anti-Xa agents with PCC or andexanet alfa, where available. Blood pressure lowering may reduce hematoma growth and improve clinical outcomes and careful (avoiding reductions ≥60 mm Hg within 1 h), targeted (as low as 120–130 mm Hg), and sustained (minimizing variability) treatment during the first 24 h may be optimal for achieving better functional outcomes in mild-to-moderate severity acute ICH. Surgery for ICH may include hematoma evacuation and external ventricular drainage to treat hydrocephalus. No large, well-conducted phase III trial of surgery in ICH has so far shown overall benefit, but meta-analyses report an increased likelihood of good functional outcome and lower risk of death with surgery, compared to medical treatment only. Expert supportive care on a stroke unit or critical care unit improves outcomes. Early prognostication is difficult, and early do-not-resuscitate orders or withdrawal of active care should be used judiciously in the first 24–48 h of care. Implementation of acute ICH care can be challenging, and using a care bundle approach, with regular monitoring of data and improvement of care processes can ensure consistent and optimal care for all patients.

Original languageEnglish (US)
Pages (from-to)945-953
Number of pages9
JournalInternational Journal of Stroke
Issue number9
StatePublished - Dec 2020


  • Intracerebral hemorrhage
  • anticoagulants
  • antiplatelet drugs
  • blood pressure
  • care bundles
  • critical care
  • neurosurgery

ASJC Scopus subject areas

  • Clinical Neurology
  • Neurology


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