Table 1

Important information to obtain as soon as possible after ICH to guide prognostication and management

Question to askRationale
Is the patient taking anticoagulation or antiplatelet medications? Anticoagulant and antiplatelet use are independent predictors of haematoma expansion11 and death.12
Further details of antithrombotic treatment: what agent, what dose and when was the most recent dose (or the most recent International Normalised Ratio(INR) for warfarin)? This is relevant to establish if anticoagulation reversal is needed, and if so, the type and dose of reversal agent to be used.
What was the time of onset of symptoms? This is obviously crucial to determine in all stroke presentations, but is relevant in ICH as the time from symptom onset to baseline imaging relates inversely to the risk of haematoma expansion11 and determines whether to pursue acute blood pressure lowering. Most expansion occurs in the first few hours after ICH.13 It is also important to establish whether the imaging appearances are consistent with the time of onset; a haematoma may appear isodense with brain tissue as early as five days after the onset, so the diagnosis may be missed if CT imaging is delayed.
Is the patient’s blood pressure elevated (systolic blood pressure >150 mm Hg)? Blood pressure is frequently very high in the acute phase.14 Elevated systolic blood pressure is associated with further neurological deterioration and mortality15 16 and early treatment may be beneficial, although there is much uncertainty about this.
Has ICH been distinguished from haemorrhagic transformation of ischaemic stroke? ICH cannot always be definitely distinguished from haemorrhagic transformation of infarction on imaging.17 Features suggesting haemorrhagic transformation include a patchy rather than uniform appearance of the haematoma, hypodensity surrounding the haematoma that may reach the cortex in a wedge shape, and evidence of an occluded vessel visible in the same arterial territory.
Are there imaging or clinical signs of intraventricular extension of haemorrhage and hydrocephalus? Intraventricular extension of haemorrhage and raised intracranial pressure (ICP) from hydrocephalus each predict higher mortality and poor functional outcome18 and require urgent consideration for surgical management (external ventricular drain insertion).
Are there imaging or clinical signs of mass effect and increased ICP? Blood pressure targets may require revision if there are signs of elevated ICP, and hyperosmolar agents and ICP management may be indicated.19 20
  • ICH, intracerebral haemorrhage.