Hemorrhagic Stroke (ICH and aSAH)

Hemorrhagic stroke means blood where it does not belong: inside the brain or in the space around it. This page covers two conditions, and they start with different priorities. Intracerebral hemorrhage (ICH) is bleeding into brain tissue. Aneurysmal subarachnoid hemorrhage (aSAH) is blood leaking from a ruptured intracranial aneurysm into the cerebrospinal fluid (CSF) space.

• ICH causes: The modifiable risk factor that matters most is high blood pressure. In older adults, cerebral amyloid angiopathy is the usual cause. The deep ganglia and thalamus are the most common sites. Anticoagulant and antiplatelet drugs make the hematoma bigger and raise mortality.
• ICH course: The hematoma keeps growing in the first hours, and that growth strongly predicts death. Then the brain injures itself further through edema, inflammation and oxidative stress.
• aSAH course: Three threats matter most. Rebleeding peaks in the first 24 h. Delayed cerebral ischemia (DCI) comes mostly from vasospasm. Then there is hydrocephalus.
• Severity scales: Clinical grade in aSAH comes from the World Federation of Neurosurgical Societies (WFNS) scale or the Hunt and Hess scale. The Fisher scale grades clot burden on CT. The ICH score grades ICH.

Intracerebral hemorrhage

A sudden focal deficit (weakness, numbness, gaze deviation, speech change) often comes with headache, vomiting or reduced consciousness. High blood pressure is often present too. You cannot tell ICH from ischemic stroke at the bedside. The prehospital stroke screen finds the stroke. CT finds the bleed.

Aneurysmal subarachnoid hemorrhage

Think thunderclap: a headache that peaks within 1 hour, often with neck pain or stiffness, vomiting or collapse. The Ottawa SAH rule was validated in adults with a headache that peaks within 1 hour and no neurologic deficits. Its job is to rule SAH out. It cannot confirm it. One positive item means investigate: age 40 or older, neck pain or stiffness, witnessed loss of consciousness, onset during exertion, thunderclap headache, or limited neck flexion on exam.

Red Flags

• Falling GCS or new drowsiness: Treat it as hematoma growth, hydrocephalus or rebleeding until you prove otherwise.
• Unequal pupils, new gaze deviation or posturing: Think herniation. Give osmotic therapy per protocol.
• Vomiting with headache: Think raised intracranial pressure (ICP).
• Anticoagulant or antiplatelet use: ask for the drug, the dose and the time of the last dose.
• Seizure: A seizure can be the first sign of ICH or aSAH. Treat per protocol.

Non-contrast head CT is the first test for both conditions. Don't hold the reversal and blood pressure pathway for lab results. Start it from the scene.

Scope check: this is airway and oxygen basics, positioning, monitoring and early notification. Blood pressure lowering, reversal and seizure treatment belong to ALS or the hospital.

1. Airway: keep the airway clear; suction vomit; position so the airway stays protected. Escalate to an advanced airway per protocol if GCS falls.
2. Oxygen: titrate to SpO₂ of 94% or higher and avoid hyperoxia, per protocol.
3. History: time of last known well or sudden onset, warfarin or direct oral anticoagulant (DOAC), heparin or enoxaparin, aspirin or clopidogrel, thrombolytic therapy given for a stroke, and the time of the last dose. Bring the pill bottles if they are available.
4. Glucose: check glucose and treat low glucose (below 60 mg/dL) per protocol.
5. Monitoring: blood pressure, heart rate, SpO₂, GCS and pupils, repeated with each change and per protocol.
6. Transport: early notification and direct transport to a stroke center or neurosurgical center; see Transport Considerations.

Doses vary by protocol; follow local protocols and medical direction.

• Blood pressure, ICH (Paramedic/RN/CCT, where protocol allows): lower systolic BP (SBP) toward 140 mmHg with a titratable IV infusion. Start within 2 hours of onset and reach the target within 1 hour of starting treatment (AHA 2022, class 2a for timing). Maintain 130–150 mmHg (class 2b). Avoid SBP below 130 mmHg when the presenting SBP was above 150 mmHg (class 3, harm) and avoid large swings. Check BP every 5–15 minutes and titrate stepwise. The target applies to mild-to-moderate ICH with presenting SBP 150–220 mmHg. Nicardipine or labetalol; see Nicardipine and Labetalol. Clevidipine is an alternative: Clevidipine.
• Warfarin (Paramedic/RN/CCT, where stocked): 4-factor PCC by INR: 25 units/kg for INR 2 to under 4 (max 2,500 units), 35 units/kg for INR 4 to 6 (max 3,500 units), 50 units/kg for INR above 6 (max 5,000 units). Give IV vitamin K 5–10 mg, no faster than 1 mg/min, with the PCC. Vitamin K carries a boxed warning for fatal hypersensitivity with IV use, so infuse slowly and monitor. PCC is preferred over fresh-frozen plasma (AHA 2022, class 1). For INR 1.3–1.9, PCC may be considered (class 2b). Kcentra carries a boxed warning for arterial and venous thromboembolic complications and is contraindicated with known HIT or DIC. Monitor INR and clinical response after treatment. The timing of restarting anticoagulation is set with neurology per local protocol. See 4-Factor PCC and Vitamin K.
• Heparin and enoxaparin: IV protamine per protocol. Dose from the heparin amount still circulating (see Protamine), give slowly, and never faster than 50 mg in 10 minutes. Protamine can cause hypotension, bradycardia and anaphylaxis, so have resuscitation drugs available. For enoxaparin, protamine is partial reversal only (AHA 2022: UFH class 2a; LMWH class 2b).
• Dabigatran: idarucizumab 5 g IV (two 2.5 g vials). If idarucizumab is unavailable, PCC may be considered per protocol.
• Factor Xa inhibitors (apixaban, rivaroxaban, edoxaban): the NCS/SCCM 2026 focused update prefers 4-factor PCC over andexanet alfa (conditional). AHA 2022 ranks andexanet alfa as reasonable (class 2a) and PCC as may be considered (class 2b), so the two sources differ. Use local protocol and stock; PCC for factor Xa reversal is off-label.
• Antiplatelet drugs (aspirin, clopidogrel): do not give platelet transfusion for spontaneous ICH outside neurosurgical care (NCS/SCCM 2026). Platelets are considered for aspirin patients undergoing surgery. See Blood Components.
• Tranexamic acid: not given for ICH outside a trial. See Tranexamic Acid.
• Thrombolytic-associated ICH (after alteplase or tenecteplase for ischemic stroke): stop the infusion, repeat CT, and check CBC, coagulation tests and fibrinogen. Treat per local protocol and neurology, which may include cryoprecipitate or an antifibrinolytic.
• Seizure: treat clinical seizure per protocol. Routine prophylactic antiseizure drugs are not beneficial in ICH (AHA 2022 guideline). See Levetiracetam.
• Airway: advanced airway with waveform capnography if the airway is not protected. Protect blood pressure and oxygenation during intubation. See Intubation.

Intracerebral hemorrhage

• Blood pressure: Start BP lowering within 2 hours of onset, on a continuous infusion where possible. Reach SBP 140 mmHg within 1 hour of starting (AHA 2022, class 2a for timing and careful titration). Aiming for 140 and holding 130–150 mmHg is class 2b. Avoid SBP below 130 mmHg when the presenting SBP was above 150 mmHg (class 3, harm). No target is established for SBP above 220 mmHg or for large hematomas. Neurocritical care sets those. See Nicardipine.
• Anticoagulation: Reversal follows the table in ALS Management. For warfarin, vitamin K and 4-factor PCC go in together.
• Tranexamic acid: Don't use it outside a trial. A 2026 individual patient data meta-analysis of nine randomized trials (3,194 patients) found no gain in 90-day functional outcome. It did reduce 7-day mortality and hematoma expansion.
• Glucose and temperature: Glucose above 180 mg/dL and below 60 mg/dL both get treated per protocol (AHA 2022 guideline). Fever is treated with drugs, for example with IV acetaminophen. Routine therapeutic hypothermia is not recommended.
• ICP and airway: Raise the head of the bed per protocol, and skip hypotonic fluids. Avoid hyperventilation, except as a short bridge for herniation. The ETCO₂ target comes from protocol. Protect hemodynamics during intubation. Consider ICP monitoring for coma or hydrocephalus, per neurocritical care.
• Swallowing and VTE: Screen swallowing before anything goes by mouth. Intermittent pneumatic compression starts on the day of diagnosis (AHA 2022, class 1). Low-dose UFH or LMWH may be reasonable from 24 to 48 hours after onset (class 2b).
• EEG: When mental status is unexplained or keeps changing, continuous EEG for 24 hours or more is reasonable (AHA 2022, class 2a).
• Neurosurgery: Cerebellar bleed with deterioration, brainstem compression or hydrocephalus: surgery is recommended. For a supratentorial bleed, consider minimally invasive evacuation in selected patients, per neurosurgery and local expertise.
• Osmotic therapy: Herniation signs call for osmotic therapy: Mannitol or 3% saline, per protocol.

Aneurysmal subarachnoid hemorrhage

• Aneurysm securing: Treat the aneurysm as early as feasible, ideally within 24 hours of onset, once the patient is hemodynamically stable. Early repair cuts rebleeding.
• Blood pressure before securing: Neurosurgery and neurocritical care set the target. The AHA 2023 guideline gives no single SBP target, and practice varies. Avoid both severe hypertension and hypotension until the aneurysm is secured. Use a titratable, short-acting agent.
• Nimodipine: 60 mg by mouth or nasogastric tube every 4 hours for 21 days, started within 96 hours of onset. Enteral only. IV nimodipine is not used. If hypotension develops, discuss a split dose of 30 mg every 2 hours or a held dose with the prescriber. Don't swap in IV nicardipine or another IV calcium channel blocker. In cirrhosis, the dose comes down to 30 mg every 4 hours. Avoid strong CYP3A4 inhibitors.
• Antifibrinolytics: Routine tranexamic acid to prevent rebleeding is not part of aSAH care (2025 German-speaking consensus).
• Sodium and volume: Protect euvolemia and sodium. Don't restrict fluid for hyponatremia. Cerebral salt wasting is treated per neurocritical care.
• Cardiac and pulmonary: ECG changes, a troponin rise and neurogenic stunned myocardium are common. Neurogenic pulmonary edema can happen too. Monitor and treat per protocol.
• Seizures, glucose and temperature: Treat clinical seizures per protocol. Prophylaxis practice varies, so follow the neurocritical care protocol. Manage glucose and fever the same way as in ICH.
• DCI prevention: For DCI prevention, use nimodipine and maintain euvolemia. Avoid hypervolemia and prophylactic hemodynamic augmentation. IV nicardipine is not recommended for DCI prevention.
• Symptomatic vasospasm: Hemodynamic augmentation is a weak recommendation. The 2025 consensus recommends transcranial Doppler for screening and monitoring.
• Hydrocephalus: CSF is drained by external ventricular drain (EVD) or lumbar drain. Ventriculostomy is the method of choice with obstructive hydrocephalus. Whether EVD drainage runs continuously or on demand is not settled.

• Destination: Go to a center with neurosurgery, a neurocritical care unit and, for aSAH, aneurysm treatment. Neuro-specific ICU care is reasonable (AHA 2022, class 2a). Transfer is recommended when the local hospital cannot treat the aneurysm or the hemorrhage surgically. Stabilize BP before transfer, and place an EVD if hydrocephalus is causing deterioration, per local protocol.
• Continue in transit: Keep the BP infusion running, with checks at each titration step. Plan the q4h nimodipine times around the transfer (enteral only). Match the nicardipine bag concentration to the pump (see Nicardipine). A delayed transfer is your cue to reassess the anticoagulant reversal and the BP plan.
• Monitor: GCS, pupils, BP, SpO₂ (94% or higher), glucose and seizure activity. Add waveform capnography if intubated.
• Handoff essentials: time of onset or last known well, anticoagulant or antiplatelet with last dose, reversal given and time, BP target and infusion rate, nimodipine times and last dose, EVD status, and neurologic exam trend.

• Pediatrics: Spontaneous ICH is rare in children. One 148-child single-centre retrospective series (2025) found vascular and unknown causes most common. That is one series, so it is not guidance. No pediatric ICH BP target is established. Think about arteriovenous malformation (AVM) and coagulopathy, and add vitamin K deficiency bleeding in neonates. Weight-based dosing and reversal are set by pediatric neurosurgery, hematology and pediatric neurocritical care. See weight-based dosing.
• Pregnancy: Treat severe-range blood pressure per obstetric protocol, with the first-line agents on the Labetalol and Nicardipine pages. Eclampsia and posterior reversible encephalopathy syndrome (PRES) can mimic this, so consider both. Magnesium is used for eclampsia per obstetric protocol. Don't delay CT or MRI when intracranial bleeding is suspected.
• Older Adults: Cerebral amyloid angiopathy is the main cause, and it bleeds in the lobes. No specific BP target change is established, so run the same ICH pathway. Don't make a do-not-resuscitate decision on the ICH score alone (AHA 2022 guideline).
• Renal Impairment: No specific adjustment is established for the ICH BP pathway. Titrate nicardipine gradually and watch for accumulation.
• Hepatic Impairment: In cirrhosis the label halves the nimodipine dose to 30 mg every 4 hours. Watch BP and heart rate closely.
• Patients on Anticoagulants: Reverse per the ALS Management table, using the current INR and weight. Dabigatran gets idarucizumab, not PCC.
• Patients on Antiplatelet Agents: Platelets are not given routinely outside neurosurgical care. See ALS Management.

• Error: IV nimodipine. It is enteral only, so check the route on every order and every handoff.
• Error: BP drop too fast. In ICH, the trap is dropping SBP below 130 mmHg when the presenting SBP was above 150 mmHg. Avoid big, abrupt falls in BP. Titrate one step at a time.
• Error: Routine tranexamic acid or platelets. Neither one is recommended for ICH on antiplatelets, or for ICH in general outside a trial.
• Error: Missed anticoagulant. Plenty of patients take a DOAC, heparin or enoxaparin. Find the drug and the last dose, then check the drug-specific reversal pathway before you choose a reversal agent.
• Error: Normal exam, positive rule. A thunderclap headache with a normal neurologic exam still needs investigation when the Ottawa SAH rule is positive.