Patient handout

Intracerebral Hemorrhage

PRODUCTION

1. Your condition

This handout is for intracerebral hemorrhage. Your care team identified this based on: acute focal deficit with sudden severe headache (aha/asa 2022).

Other reasons your team may use this plan: altered consciousness / gcs drop (hemphill stroke 2001); new seizure with focal deficit (aha/asa 2022); non-contrast ct head showing intraparenchymal blood (aha/asa 2022).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
nicardipine	5 mg/h IV; titrate by 2.5 mg/h q5–15 min	IV	continuous infusion	INTERACT3 (Ma Lancet 2023) / ATACH-2 (Qureshi NEJM 2016) — target SBP 130–150 within 1 h reduces hematoma growth + improves functional outcome
clevidipine	1–2 mg/h IV; double q90 sec	IV	continuous	Ultra-short acting; useful when frequent titration needed (AHA/ASA 2022)
labetalol	10–20 mg IV bolus q10 min; or 2–8 mg/min infusion	IV	PRN / infusion	Adjunct for resistant HTN or when CCBs contraindicated (AHA/ASA 2022)

Plan: INTERACT3 (Ma Lancet 2023 PMID 37245517) acute care bundle — BP, reversal, glucose, temp, surgery

3. When to call your provider

Contact your care team if any of the following happen:

Any new TIA-spectrum or stroke-like event → ED (AHA/ASA 2022)
BP persistently >140/90 despite 3-drug regimen → resistant HTN workup (AHA/ASA 2022)
PHQ-9 ≥15 OR suicidal ideation → urgent psych referral (AHA/ASA 2022)
MoCA <26 OR cognitive decline noted by family → neurocognitive workup (AHA/ASA 2022)
Recurrent ICH → re-image, hold any antithrombotic, escalate to vascular neurology (AHA/ASA 2022)
New CAA microbleeds on 6-mo MRI → reinforce anticoag-hold; consider LAA closure if AF (AHA/ASA 2022)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Hematoma volume increase >33% on repeat CT (AHA/ASA 2022)
Cerebellar ICH ≥3 cm OR brainstem compression OR hydrocephalus (AHA/ASA 2022)(life-threatening)
Cushing reflex, anisocoria, GCS decline ≥2, posturing (AHA/ASA 2022)(life-threatening)
IVH on CT with ventricular enlargement + GCS decline (AHA/ASA 2022)
Patient on VKA / DOAC / heparin with confirmed ICH (AHA/ASA 2022)
GCS ≤8 at presentation or decline (Hemphill Stroke 2001)(life-threatening)
SBP not at <140 within 1 h of ED arrival despite first-line IV antihypertensive (INTERACT3 Ma Lancet 2023 PMID 37245517)
Lobar ICH (cortico-subcortical) on CT; age >55; multiple cortical/subcortical microbleeds on MRI GRE/SWI per Boston v2.0; absence of hypertensive history
Deep ICH in basal ganglia / thalamus / internal capsule on CT; long-standing hypertension; absence of lobar microbleed burden on MRI
Cerebellar ICH ≥3 cm OR brainstem compression OR obstructive hydrocephalus from cerebellar mass effect (AHA/ASA 2022 Class I)(life-threatening)
Pontine or brainstem ICH on CT (typically hypertensive); GCS often ≤8; quadriparesis + cranial nerve deficits(life-threatening)
Predominant IVH on CT with or without small parenchymal source; obstructive hydrocephalus common
Effect-size + special-population matrix (data, not a runtime gate): INTERACT2 ordinal mRS OR 0.87 (95% CI 0.77-1.00; p=0.04), mortality 11.9% vs 12.0% (Anderson NEJM 2013 PMID 23713578); INTERACT3 goal-directed care bundle (SBP 130-150 within 1 h + glucose + pyrexia + anticoagulation algorithms) improved 6-mo functional outcome (Ma Lancet 2023 PMID 37245517); ATACH-2 intensive (SBP 110-139) vs standard death/disability 38.7% vs 37.7%, renal AE 9.0% vs 4.0% (p=0.002) → avoid SBP <110 (Qureshi NEJM 2016 PMID 27276234); ANNEXA-I andexanet vs usual care superior haemostatic efficacy for FXa-DOAC ICH, n=263 vs 267 (Connolly NEJM 2024 PMID 38749032); INCH INR ≤1.2 within 3 h 4F-PCC 67% vs FFP 9% (adjusted OR 30.6, 95% CI 4.7-197.9; p=0.0003) (Steiner Lancet Neurol 2016 PMID 27302126); PATCH platelet transfusion in antiplatelet ICH death/dependence adjusted common OR 2.05 (95% CI 1.18-3.56; p=0.0114) — HARM (Baharoglu Lancet 2016 PMID 27178479); ENRICH minimally invasive evacuation (lobar/anterior-BG 30-80 mL <24 h) superior mean utility-weighted mRS at 180 d, posterior probability >0.975 (Pradilla NEJM 2024 PMID 38598795); ICH Score → 30-d mortality 0→0%, 1→13%, 2→26%, 3→72%, 4→97%, 5→100% (Hemphill Stroke 2001 PMID 11283388); FUNC score ≤4 → 0% vs 11 → >80% 90-d functional independence, n=629 (Rost Stroke 2008 PMID 18556582); CTA spot sign first-pass sens 53% spec 88%, LR+ 4.70 (3.28-6.74) LR- 0.44 (0.34-0.58); combined modalities LR+ 6.76 LR- 0.17 (Du PLoS One 2014 PMID 25541717); spot-sign frequency 39% (<2 h) → 13% (>8 h) and PPV 53%→33% with onset-to-CTA time (Dowlatshahi Stroke 2016 PMID 26846857) — spot-sign LR is time-conditional; lobar/CAA annual recurrent-ICH risk ≈7%/yr; brainstem ICH 90-d mortality ≈50-80% (AHA/ASA 2022 PMID 35579034).

5. Follow-up

Long-term BP <130/80 (SPRINT-MIND); anticoag-restart 4–8 wk decision (AF high CHA2DS2-VASc favours restart; CAA contraindicates restart); CAA family + amyloid counselling; rehab; PHQ-9 depression screen at 90 d (AHA/ASA 2022)

6. Sources

Guideline: 2022 AHA/ASA Guideline for Spontaneous ICH (Greenberg Stroke 2022) + INTERACT3 care bundle + ANNEXA-I + ENRICH evacuation