For patients with ICH taking antiplatelet agents, the PATCH trial, a RCT in the Netherlands, United Kingdom, and France, randomized 190 patients with supratentorial ICH and a GCS >8 who had received antiplatelet therapy (mostly aspirin alone) within seven days to standard care or care with platelet transfusion.

An ordinal analysis looking at modified Rankin score and death showed an odds ratio of death of 2.05 in the treatment group. More serious adverse events were reported in patients who received platelet transfusion (42 percent) compared with patients who received standard care alone (29 percent). The researchers concluded that platelets were associated with poorer clinical outcomes overall.⁵ It is important to note that these patients were primarily nonsurgical ICH patients. For patients requiring emergency surgery, most neurosurgeons recommend platelet transfusion for patients taking antiplatelet agents.

Reversal of warfarin: Any patient taking warfarin who presents to the emergency department with ICH should receive IV four-factor prothrombin complex concentrates (PCCs) 1,500 units (Octaplex, Beriplex, or Kcentra) as soon as possible and IV vitamin K 10 mg in 50 mL of normal saline over 10 minutes. Treatment should not be delayed for the international normalized ratio results to come back, as hematoma expansion typically occurs within the first hour in patients taking warfarin.⁶

Reversal of dabigatran: Idarucizumab is the reversal agent of choice for dabigitran despite the lack of evidence for improved patient outcomes.⁶ If idarucizumab is not available, consider factor eight inhibitor bypass activity (FEIBA). If FEIBA is not available consider four-factor PCC.

Reversal of Xa inhibitors: For Xa inhibitors (eg, apixaban, rivaroxaban) 4-factor PCC at a dose of 50 IU/kg up to 3,000 units is the reversal agent of choice based on limited evidence. Andexanet alfa is a decoy antigen; it competitively binds rivaroxaban and apixaban and is given as an ongoing infusion. The evidence is not convincing for its effectiveness.⁶

Glucose Control

Hyperglycemia is common in patients presenting with ICH and is associated with poor outcomes.⁷ The optimal glucose level and the best hyperglycemia management strategy remain undecided. However, both hypoglycemia (<70 mg/dL) and hyperglycemia (>180 mg/dL) should be avoided. A study suggested improved clinical outcomes with tight control of blood sugar to the range of 80 to 110 mg, but this was found to cause occasional hypoglycemia resulting in increased mortality.⁸

Temperature Control in ICH

So-called “brain blood fever” is common in ICH, with 30 to 50 percent of patients developing fever. The presence of intraventricular hemorrhage is the main risk factor for fever. Fever is independently associated with poor outcomes. While there are no available data from RCTs addressing the role of induced normothermia after ICH, current recommendations are to cool febrile ICH patients to a core temperature below 37.5 to 38 °C.⁹

Management of Elevated ICP

Management of elevated ICP starts with meticulous airway management for those patients whom you deem at risk for aspiration. Keep the head of the bed elevated at least 20 degrees to prevent spikes in ICP. Titrate systolic BP to 140 to 160, preferably with an arterial line in place. Consider fentanyl 3–5 mcg/kg pretreatment three minutes before intubation, but beware of the possibility of apnea and provide appropriate analgesia and sedation postintubation. Avoid hypoxemia and hypotension at all costs in ICH. Hyperventilation to a PCO2 of 30 to 35 is only recommended as a temporary bridge to definitive surgical management in those patients who are actively coning.