Intracerebral hemorrhage is bleeding directly into the brain tissue, most often from long-standing high blood pressure or a blood thinner. The blood clot can grow in the first hours and raise pressure in the skull, so fast diagnosis and treatment matter.
Key symptoms
- Sudden weakness or numbness of one side
- Trouble speaking or understanding speech
- Severe headache with nausea and vomiting
- Drowsiness or loss of consciousness
What you find on exam
- Airway, breathing and level of consciousness with the Glasgow Coma Scale
- Stroke scale with focal deficits
- Very high blood pressure is common
- Pupils and signs of brain herniation
Tests
- Non-contrast CT head right away: bright area of blood
- Coagulation tests (INR, aPTT), platelets and glucose
- CT angiography to look for an aneurysm, malformation or spot sign
- Ask about anticoagulants and time of last known well
Treatment basics
- Lower systolic blood pressure toward about 140 mmHg with nicardipine or labetalol
- Reverse anticoagulation: prothrombin complex concentrate with vitamin K for warfarin, specific reversal for DOACs
- Elevate the head of the bed and protect the airway
- Neurosurgery consult for large or cerebellar bleeds or hydrocephalus
Red flags
- Falling Glasgow Coma Scale score
- A fixed, dilated pupil
- Bleeding while on a blood thinner
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; NASEMSO National Model EMS Clinical Guidelines. Written by Making Synapses. Making Synapses is not affiliated with these organizations.