Feature Film - Is There Evidence Behind the Management of Spontaneous Intracerebral Hemorrhage?

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  • Intracerebral hemorrhage (ICH) accounts for 10-15% of all strokes and affects ~65,000 patients annually in the US. Mortality ranges from 35-52% and only 20% are functionally independent at six months.

  • Once the diagnosis has been made, the emergency provider should focus on preventing hematoma expansion, optimizing cerebral perfusion and ensuring the best environment for recovery.

Here are the Cliff Notes to Dr. Siket’s Lecture Below

  • The ‘CTA Spot Sign’ is one predictor of early expansion and poor outcome.

  • Warfarin and novel oral anticoagulant associated ICH should be reversed early and aggressively.

  • Reversing antiplatelet medications is not recommended.

  • Surgery is indicated for most cerebellar ICH.

  • Intraventricular hemorrhage and hydrocephalus should be treated with placement of an external ventricular drain.

  • Aggressive BP lowering is safe, but has not been shown to be beneficial.

  • Close management of glucose, temperature, and dysphagia impacts survival.

  • Routine seizure prophylaxis is not supported by evidence.

  • In severe ICH it is reasonable to trial aggressive medical management for 1-2 days in accordance with family wishes.



Matthew S. Siket, MD, MS

Assistant Professor of Emergency Medicine

Warren Alpert Medical School of Brown University

Providence, RI




  1. Broderick J et al. Circulation 2007

  2. Brott et al. Stroke 1997

  3. Brouwers HB et al. JAMA Neurol 2014

  4. Steiner T. et al, Lancet Neurology April 2016

  5. Pollack et al, NEJM 2015

  6. Miller L et al. J Emerg Med 2016

  7. Connolly, SJ et al, NEJM 2016

  8. Baharoglu MI et al. Lancet 2016

  9. Prodan CI. Lancet 2016

  10. Mendelow et al. Lancet 2005

  11. Mendelow et al. Lancet 2013

  12. Naff N, et al. Stroke 2011

  13. De Oliveira Manoel et al. Critical Care 2016

  14. Hemphill JC et al. Stroke 2015

  15. Balami JS Buchan AM Lancet Neurol 2012

  16. Elliott J Smith M. Anesth Analg 2010

  17. Kate MP et al. J Cereb Blood Flow Met 2014

  18. C. S. Anderson et al. NEJM 2013

  19. AI Qureshi et al, NEJM 2016

  20. Kuramatsu JB et al. JAMA 2015

  21. Middleton et al. Lancet Neurology 2011

  22. Frontera JA et al. Neurocrit Care 2016

  23. Messe SR et al. Neurocrit Care 2009

  24. Naidech AM et al. Stroke 2009