Study guide
Acute Intraparenchymal Hemorrhage Management
ABPN Neurocritical Care Study Guide Exam
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1 Chapter 1: Neurologic Examination & Coma Assessment in the ICU
Current Examination, Blueprint & Preparation Neurologic Examination in Critically Ill Patients Coma Evaluation & Consciousness Alterations Delirium & Toxic-Metabolic Encephalopathy in the ICU
2 Chapter 2: Cerebral Physiology & Intracranial Dynamics
Cerebral Blood Flow, Metabolism & Autoregulation Intracranial Pressure & Compliance Cerebral Edema & Herniation Syndromes
3 Chapter 3: Intracranial Hypertension & Cerebral Perfusion Management
Tiered ICP Management Protocols Hyperosmolar Therapy & Fluid Management Advanced & Refractory ICP Interventions
4 Chapter 4: Airway, Mechanical Ventilation & Pulmonary ICU Management
Emergency Airway Management & Neuro-Intubation Mechanical Ventilation Strategies in Acute Brain Injury Tracheostomy & Ventilator Weaning in Neurocritical Care Pulmonary Complications in the Neuro-ICU Obstructive Lung Disease, Pulmonary Hypertension & Bronchoscopy
5 Chapter 5: Hemodynamics, Shock & Cardiovascular Management
Hemodynamic Monitoring & Blood Pressure Targets Vasoactive Agents: Inotropes, Vasopressors & Antihypertensives Cardiac Complications of Brain Injury
6 Chapter 6: Neuropharmacology, Analgesia & Sedation
ICU Sedation & Analgesia Neuromuscular Blockade & Monitoring Propofol Infusion Syndrome & Drug Toxicities Antiseizure Drug Pharmacology in the ICU
7 Bleeding, Thrombosis & Hematologic Emergencies
Warfarin & Heparin Reversal Direct Oral Anticoagulant (DOAC) Reversal Antiplatelet Management & Platelet Dysfunction Venous Thromboembolism Prophylaxis & Management Transfusion, Coagulopathy, TMA & Cellular-Therapy Neurotoxicity
8 Chapter 8: Systemic ICU Care, Fluids, Electrolytes & Endocrine
Hyponatremia & Osmoregulation: SIADH vs Cerebral Salt Wasting Diabetes Insipidus, Hypernatremia & Endocrine Crises Critical Care Prophylaxis, Nutrition & Infection Prevention
9 Systemic Trauma & Environmental Injury
Polytrauma, Chest Injury & Abdominal Hemorrhage Burns, Electrical Injury & Hanging
10 Cardiac Emergencies & Mechanical Support
IABP, Ventricular Devices & ECMO Acute Coronary, Valvular, Rhythm & Aortic Emergencies
11 Kidney Injury, Acid–Base & Renal Replacement
Acute Kidney Injury & Renal Drug Clearance Acid–Base Disorders, Electrolytes & Renal Replacement
12 Systemic Infection & Endocrine Emergencies
Sepsis, Endocarditis & Antimicrobial Principles Thyroid, Adrenal & Dysglycemic Emergencies
13 Gastrointestinal & Hepatic Emergencies
Acute Abdomen, GI Bleeding & Abdominal Compartment Syndrome Acute Liver Failure, Cirrhosis & Hepatic Drug Effects
14 Chapter 9: Neuroimaging in the Neuro-ICU
Non-Contrast CT & CT Angiography CT Perfusion & Advanced Perfusion Imaging Magnetic Resonance Imaging in Critical Illness
15 Chapter 10: Electrophysiology & Neuromonitoring
Continuous EEG & ACNS Standardized Critical Care Terminology Invasive Neuromonitoring: ICP & External Ventricular Drains Multimodal Monitoring: PbtO2, Microdialysis & Transcranial Doppler
16 Angiography, Electrodiagnosis & CSF Analysis
Conventional Angiography & Cranial–Spinal Shunts EMG, Nerve Conduction & Acute Muscle Disease CSF Analysis: Infection, Inflammation & Hemorrhage
17 Chapter 11: Bedside Procedures, Ultrasound & Death by Neurologic Criteria
Critical Care Procedural Skills Critical Care Ultrasound & Echocardiography Determination of Death by Neurologic Criteria
18 Chapter 12: Acute Ischemic Stroke & Reperfusion Therapies
Acute Ischemic Stroke Management & Thrombolysis Endovascular Thrombectomy & Large Vessel Occlusion Malignant Hemispheric & Cerebellar Infarction
19 Chapter 13: Spontaneous Intracerebral Hemorrhage & Intraventricular Hemorrhage
Acute Intraparenchymal Hemorrhage Management Intraventricular Hemorrhage & Hydrocephalus Surgical Evacuation & Minimally Invasive Surgery in ICH
20 Chapter 14: Aneurysmal Subarachnoid Hemorrhage & Delayed Cerebral Ischemia
Aneurysmal Subarachnoid Hemorrhage: Acute Resuscitation & Securing Delayed Cerebral Ischemia & Cerebral Vasospasm Non-Aneurysmal Subarachnoid Hemorrhage & Vascular Malformations
21 Venous, Spinal & Traumatic Vascular Disease
Cerebral Venous Thrombosis & Spinal Cord Infarction Traumatic Dissection, Carotid–Cavernous Fistula & Penetrating Injury
22 Chapter 15: Traumatic Brain & Spinal Cord Injury
Severe Traumatic Brain Injury & Contusions Acute Traumatic Spinal Cord Injury & Neurogenic Shock Spine Trauma, Fractures & Cord Syndromes
23 Chapter 16: Status Epilepticus, Seizures & Neuromuscular Emergencies
Status Epilepticus: Convulsive & Non-Convulsive Refractory & Super-Refractory Status Epilepticus Acute Neuromuscular Respiratory Failure
24 Chapter 17: Post-Cardiac Arrest Care, CNS Infections & Encephalitis
Targeted Temperature Management & Post-Cardiac Arrest Care Post-Cardiac Arrest Neuroprognostication Acute CNS Infections, Encephalitis & Inflammatory Emergencies
25 Neuroinflammation & Neurooncology
Fulminant Demyelination & Autoimmune Encephalitis Brain, Spinal & Leptomeningeal Cancer Emergencies
26 Pregnancy, Transplantation & Pediatric Care
Pregnancy, Postpartum & Post-Transplant Neurologic Care Pediatric Neurocritical Care
27 Chapter 18: Neurosurgical & Perioperative Emergencies
Postoperative Neurosurgical Complications Device Complications: EVDs, Shunts & ICP Monitors Cerebral Hyperperfusion Syndrome & Post-Interventional Emergencies
28 Chapter 19: Ethics, Palliative Care & Organ Donation in the Neuro-ICU
Communication, Surrogate Decision-Making & Conflict Resolution Neuroprognostication Ethics, Withdrawal of Life Support & Palliative Care Organ Donation & Management of the Deceased Donor
Acute Intraparenchymal Hemorrhage Management
Key Takeaways Explain This Topic AI
Assess location, hematoma volume, ventricular extension, mass effect, vascular causes, and relevant antithrombotic exposure urgently.
In mild-to-moderate ICH presenting with SBP 150–220 mm Hg, targeting 140 and maintaining 130–150 is reasonable; severe cases and other presentations require individualization.
ICH score components are GCS, volume, IVH, infratentorial origin, and age; the score must not determine an individual prognosis or treatment limitation alone.
For a US guide as of October 2026, do not present andexanet as routinely available: US sales ended in December 2025 following FDA safety concerns.
Last updated: October 2026
- Acute Spontaneous Intracerebral Hemorrhage
- Diagnose the Hemorrhage and Its Cause
Obtain emergency noncontrast CT while stabilizing airway, oxygenation, circulation, and glucose. Record onset or last known well, neurologic examination, baseline function, antithrombotic medications, recent procedures, trauma, hypertension, substance exposure, and bleeding history. Look for ventricular extension, hydrocephalus, posterior fossa involvement, mass effect, and herniation. Repeat imaging according to the early course and immediately for deterioration. A stable first scan does not exclude subsequent expansion.
Deep basal ganglia, thalamic, pontine, or cerebellar hemorrhage commonly reflects hypertensive small-vessel disease. Lobar hemorrhage in an older adult raises concern for cerebral amyloid angiopathy, but location alone does not prove the cause. Anticoagulation, vascular malformation, aneurysm, venous thrombosis, tumor, hemorrhagic transformation, and other mechanisms must be considered. Use vascular imaging, selected catheter angiography, and MRI according to age, location, risk factors, and the initial findings. A seemingly typical location does not make every secondary investigation unnecessary.
CAA involves amyloid deposition in cortical and leptomeningeal vessels and is associated with lobar hemorrhage, strictly lobar microbleeds, and cortical superficial siderosis. Boston v2.0 clinical categories combine age, presentation, imaging, and exclusion of other causes; mixed deep and lobar lesions complicate classification. Deep hemorrhagic lesions preclude particular probable-CAA imaging categories, but that does not prove that mixed small-vessel pathology cannot coexist biologically.
Blood Pressure and General Stabilization
The 2022 AHA/ASA guideline supports smooth, sustained pressure control with avoidance of large variability. For mild-to-moderate ICH presenting with SBP 150–220 mm Hg, targeting 140 and maintaining 130–150 is reasonable. Lowering below 130 in this setting is potentially harmful. The safety and benefit of intensive lowering are less established in large or severe hemorrhage, surgical decompression, and other presentations. Marked hypertension above 220 requires careful individualized management rather than an automatic identical target.
Nicardipine, clevidipine, or appropriately selected labetalol can provide titratable treatment. Agent choice depends on heart rate, cardiac function, airway disease, access, and local protocol. A continuous infusion is useful for sustained control, but not every bolus is categorically prohibited. Verify cuff and arterial measurements, avoid overshoot during sedation or intubation, and evaluate kidney function and systemic perfusion.
INTERACT2 had a neutral primary dichotomous endpoint with a favorable ordinal outcome signal. ATACH-2 did not improve death or disability with its more intensive strategy and reported more renal adverse events. Neither trial proves a single universal physiologic cliff at an exact SBP. INTERACT3 supported a coordinated care bundle involving pressure, glucose, temperature, and reversal rather than attributing the entire outcome to one component. Avoid severe hyperglycemia and hypoglycemia, treat fever and its cause, perform dysphagia assessment, and arrange appropriate nursing and rehabilitative care.
Measure Severity Without Creating Certainty
The ICH score assigns points for GCS 3–4 (two) or 5–12 (one), volume at least 30 mL (one), IVH (one), infratentorial origin (one), and age at least 80 (one). For example, a 74-year-old with GCS 10, a 36-mL thalamic hemorrhage, and IVH has three points: one each for GCS, volume, and IVH. The thalamus is supratentorial and age contributes zero.
The ABC/2 method estimates volume from greatest diameter A, perpendicular diameter B on the same slice, and approximate craniocaudal extent C. With dimensions 4, 3, and 5 cm, the estimate is 30 mL. Irregular, multilobulated, or heterogeneous hemorrhage can make this approximation inaccurate; use appropriate imaging measurement when precision matters. A CTA spot sign supports concern for expansion but does not by itself mandate an operation or justify empiric reversal in a patient without the relevant drug exposure.
Original cohort mortality estimates are group observations, not calibrated promises for an individual in contemporary care. Do not use a severity score alone to limit treatment. Sedation, hydrocephalus, seizures, organ failure, and subsequent response can change the assessment. Discuss uncertainty and known preferences early while continuing indicated stabilization.
Reverse Relevant Coagulopathy Promptly
Stop the offending anticoagulant and provide urgent drug-appropriate treatment. For warfarin-associated ICH, 4F-PCC provides faster factor replacement with less volume than plasma, and IV vitamin K supports sustained correction. Use the current INR/weight or validated institutional regimen and repeat testing. Vitamin K is infused slowly according to product instructions; it is not an undiluted rapid push. Plasma remains an option when PCC is unavailable and requires attention to transfusion risks.
Idarucizumab is specific to dabigatran. For factor-Xa inhibitors, current US availability matters: the FDA reported serious thrombotic concerns and US andexanet sales ended December 22, 2025. PCC-based nonspecific strategies are commonly used under current institutional guidance; they do not remove the drug or necessarily normalize anti-Xa activity. Normal INR, aPTT, or routine viscoelastic results do not reliably exclude clinically important DOAC exposure. Include dose timing, kidney function, drug-specific assays when available, thrombosis risk, and urgent specialist input.
Protamine reverses unfractionated heparin and incompletely reverses low-molecular-weight heparin; dosing depends on agent, amount, and elapsed time. Platelet transfusion is harmful for aspirin-associated spontaneous ICH without emergency surgery in the population addressed by the guideline. Surgical circumstances and thrombocytopenia require separate assessment. The effectiveness of desmopressin for antiplatelet-associated ICH remains uncertain. Do not transfer PATCH findings indiscriminately to every agent, procedure, or platelet disorder.
Sources: 2022 AHA/ASA ICH guideline and FDA andexanet safety update .
Decision Review
- Assessment Decision supported
- CT location and ventricular extension Identify mass effect, hydrocephalus, and possible etiology
- Anticoagulant history Select prompt drug-appropriate hemostatic treatment
- Severity score Describe group risk without determining treatment limits alone