Intracerebral and Subarachnoid Hemorrhage
Core concepts
Intracerebral hemorrhage requires rapid stabilization, blood pressure control, reversal of anticoagulation, and neurosurgical triage. Estimate volume with ABC/2, assess location, midline shift, intraventricular extension, and hydrocephalus. Lower systolic blood pressure promptly toward 130-140 mmHg when safe; avoid profound hypotension. Reverse warfarin with vitamin K and prothrombin complex concentrate, and reverse direct oral anticoagulants with specific agents when available. Platelet transfusion is not routine for antiplatelet-associated ICH. Cerebellar hemorrhage with deterioration, brainstem compression, or hydrocephalus often needs evacuation; supratentorial lobar or deep hemorrhage rarely benefits from routine surgery. External ventricular drainage treats obstructive hydrocephalus. Subarachnoid hemorrhage demands urgent aneurysm securement to prevent rebleeding. Grade with Hunt-Hess or WFNS. Nimodipine improves outcome and reduces delayed cerebral ischemia, though it may not eliminate angiographic vasospasm. Monitor for vasospasm days 3-14, hydrocephalus, hyponatremia, and cardiopulmonary complications. CT is sensitive early but less so after several days; lumbar puncture with xanthochromia helps when CT is nondiagnostic. Perimesencephalic SAH often has a benign course but still requires vascular imaging.
Traps
Do not attribute all SAH to a ruptured aneurysm; consider reversible vasoconstriction, dissection, and venous thrombosis. Do not delay aneurysm treatment for stable grade. Do not transfuse platelets routinely in ICH.
Worked example
A 60-year-old on warfarin with a 3 cm cerebellar ICH and declining consciousness: give vitamin K and PCC, control BP, and call neurosurgery for evacuation and possible EVD.