Guidelines of the Czech Neurological Society of the CMA JEP and the Czech Neurosurgical Society of the CMA JEP for the management of spontaneous intracerebral hemorrhage in adult patients –⁠ version 2026

Overview

Spontaneous intracerebral hemorrhage (SICH) represents a significant subtype of acute stroke with high morbidity and mortality. Comprehensive SICH management aims to increase survival rates and improve clinical outcomes of patients with this disease. The guidelines cover the areas of care organization, diagnosis, medical treatment (acute blood pressure lowering and hemostatic treatment), surgical treatment, prevention and treatment of complications, secondary prevention, prediction of the final clinical condition and care goals, rehabilitation and neurobehavioral complications, quality control, and discharge report requirements. The presented guidelines for the management of SICH in adult patients represent a consensus opinion of the committees of the Czech Neurological Society of the Czech Medical Association JEP, and the Czech Neurosurgical Society of the Czech Medical Association JEP.

Keywords:

management – surgical treatment – guidelines – spontaneous intracerebral hemorrhage – medical treatment – care organization

This is an unauthorised machine translation into English made using the DeepL Translate Pro translator. The editors do not guarantee that the content of the article corresponds fully to the original language version

 

1. Organization of Care

The organization of prehospital care does not differ from that for patients with suspected ischemic stroke [3].

Every patient with rapidly developing clinical symptoms of focal brain involvement within the last 24 hours should be assessed as a patient with a possible acute stroke and, as part of prehospital triage, should be transported without delay to a center for highly specialized cerebrovascular care (Comprehensive Cerebrovascular Center [KCC]) or a center providing highly specialized care for stroke patients (Stroke Center [IC]).

The destination center must ensure that care is organized in such a way as to allow the patient to be admitted either to the CT unit or to the emergency department with direct access to diagnostic resources for brain imaging.

The current guidelines for triaging patients with acute stroke in prehospital and hospital care are set forth in the current Bulletin of the Ministry of Health (MZ) of the Czech Republic No. 10/2021 [4]. Pre-hospital care is provided by the Emergency Medical Service (EMS). The current list of centers for highly specialized cerebrovascular care and centers for highly specialized care of stroke patients is published in the current Bulletin of the Ministry of Health of the Czech Republic No. 10/2021 [4].

For patients with SICH who do not require intensive care, admission to a specialized stroke unit is recommended to reduce the risk of death or disability.

 

2. Diagnosis

Basic diagnostics do not differ from those for patients with suspected ischemic stroke [3]; the specifics of imaging examinations for patients with SICH [1,2] are outlined below.

For every patient with suspected acute stroke, the following examinations should be performed as soon as possible after arrival at the hospital:

blood pressure (BP) measurement,

blood glucose measurement using a glucometer, unless already determined by EMS,

determination of the international normalized ratio (INR), particularly in patients with an unclear history of anticoagulant therapy or those taking coumarin anticoagulants (warfarin),

rapid assessment of neurological deficit and determination of its severity according to the National Institutes of Health Stroke Scale (NIHSS),

blood draws for complete blood count and coagulation parameters (prothrombin time [PT], activated partial thromboplastin time [aPTT], and in patients taking direct oral anticoagulants [DOACs] or with an unclear history of anticoagulant therapy, specific tests for DOACs—thrombin time [TT] and plasma xaban concentration; collection of these samples must not delay imaging studies.

 

Initial diagnosis using CT, including CTA, or MRI, including MRA.

In patients with SICH and/or intraventricular hemorrhage (IVH), repeat CT within the first 24 hours after symptom onset to assess progression of hematoma size.

In patients with SICH and/or IVH who have a low Glasgow Coma Scale (GCS) score or worsening neurological deficits, repeat CT may be useful to assess progression of hematoma size, development of hydrocephalus, cerebral edema, or herniation.

In patients with atypical SICH, it is recommended to consider the use of CT venography (CTV) or MR venography to select patients for DSA in order to detect intracranial vascular malformations or cerebral venous thrombosis (expert recommendation).

DSA

is recommended in patients with spontaneous IVH and without SICH to rule out a macrovascular cause;

should be performed as soon as possible in patients with SICH and findings on CTA or MRA suggesting a macrovascular cause to confirm and treat intracranial vascular malformations.

 

In patients with SICH and negative findings on CTA/CTV, it is advisable to perform an MRI after a period of time following hematoma resorption to identify causes of ICH other than macrovascular ones (e.g., cerebral amyloid angiopathy, deep perforating vasculopathy, cavernous malformation, or malignancy).

In patients with SICH who have negative DSA findings and no clear microvascular diagnosis or other defined structural lesions, it may be appropriate to repeat DSA 3–6 months after the onset of ICH to identify previously undetected vascular lesions.

 

3. Medical Treatment

3.1 Acute blood pressure reduction

In patients with SICH requiring acute blood pressure reduction, careful titration is beneficial for achieving improved functional outcomes; this ensures continuous, smooth, and sustained blood pressure control and prevents spikes and high variability in systolic blood pressure (SBP).

In patients with SICH, the following is recommended (expert recommendation):

Initiate antihypertensive therapy with a door-to-needle (DNT) time of ≤20 minutes, achieving a target SBP of <140 mmHg within 1 hour of hospital arrival, and minimizing BP variability to reduce the risk of hematoma enlargement and improve functional status.

After lowering systolic blood pressure below the target threshold, it is necessary to maintain systolic blood pressure < 140 mmHg even during the subacute phase (for up to 7 days).

Maintaining normotension is the primary goal of secondary prevention following SICH, as indicated by clinical guidelines [1,2]. For patients who have experienced SICH, a target systolic blood pressure (SBP) of <130 mmHg and a diastolic blood pressure (DBP) of <80 mmHg is recommended. According to recent analyses, achieving a systolic blood pressure (SBP) < 120 mmHg is considered desirable, as it is associated with a further reduction in the risk not only of SICH but also of other serious cardiovascular and cerebrovascular events [5]. In patients older than 75 years, achieving an SBP < 140 mmHg may be useful and sufficient.

 

In patients with SICH, it is recommended in the acute phase to avoid lowering SBP by more than 70 mmHg from baseline and to avoid actively lowering SBP below 110 mmHg.

Caution is also warranted when lowering very high systolic blood pressure (> 220 mmHg) in patients with a large hematoma volume (> 30 ml) or during planned hematoma evacuation.

 

3.2 Hemostatic Therapy

In patients with SICH associated with anticoagulant therapy, it is recommended to

to discontinue anticoagulant therapy immediately after the diagnosis of SICH is established in order to improve survival.

administration of a 4-factor prothrombin complex concentrate (PCC) in SICH associated with the use of vitamin K antagonists, at a dose ranging from 30–50 IU/kg when the INR is ≥ 2.0 and 10 IU/kg when the INR is 1.3–1.9, in combination with intravenous administration of vitamin K (10 mg) to normalize (achieve an INR < 1.3 within 1 hour of admission) and prevent subsequent increases in INR and limit the progression of hematoma size;

immediate (DNT within 20 min) administration of idarucizumab (2 × 2.5 g IV) in SICH associated with the use of a direct thrombin inhibitor (dabigatran) to normalize diluted thrombin time (dTT) and ecarin clotting time (ECT).

In cases of SICH associated with the use of factor Xa inhibitors (apixaban or rivaroxaban), administration of andexanet alfa may be considered to normalize coagulation within 15 hours of the last dose of the factor Xa inhibitor (or with a confirmed plasma concentration of xaban > 100 ng/ml) and no later than 8 hours after the onset of SICH symptoms (primarily in patients with SICH who are candidates for neurosurgical intervention, after careful consideration of the balance between its potential benefit in reducing the risk of hematoma enlargement and the potential increase in the risk of thromboembolic events, including fatal ones) [6] or administration of PCC.

In cases of SICH associated with the use of dabigatran or factor Xa inhibitors, if the DOAC was administered within the previous 2 hours (with a potential effect even if administered up to 8 hours prior), it may be appropriate to use activated charcoal to prevent absorption of the DOAC.

In cases of SICH associated with unfractionated heparin (UFH) therapy, intravenous administration of protamine sulfate is recommended to reverse the anticoagulant effect of UFH.

In cases of SICH associated with low molecular weight heparin (LMWH) therapy, consider intravenous administration of protamine sulfate to partially reverse the anticoagulant effect of LMWH.

 

In patients with SICH associated with the use of antiplatelet agents, platelet transfusion is not recommended; however, it may be considered in patients for whom urgent neurosurgical intervention is indicated to reduce postoperative bleeding and mortality.

 

4. Surgical Treatment

In patients with supratentorial SICH, it is recommended

consider a surgical approach aimed at hematoma removal and prevention of secondary brain injury to reduce the risk of death or disability, taking into account additional factors such as the location and volume of the hematoma, the patient’s neurological status, the timing of the procedure, the type of neurosurgical intervention, and the surgeon’s complication rate;

consider early surgical removal of the hematoma via open craniotomy and standard surgical evacuation techniques in patients who are not in a coma and for whom minimally invasive techniques are not available;

Use minimally invasive hematoma evacuation (MIS) in patients with lobar SICH aged 18–80 years, ideally within 8 hours (no later than 24 hours) of SICH onset, with a pre-stroke modified Rankin Scale (mRS) score of 0–1, a GCS score of 5–14, NIHSS > 5, and a hematoma volume of 30–80 ml, with the aim of reducing mortality and improving functional outcomes [7]. For deep-seated hematomas, the efficacy of surgery is unclear; therefore, these patients should be enrolled in prospective randomized trials;

consider decompressive craniectomy without hematoma removal in patients aged 18–75 years within 72 hours of the onset of severe deep SICH, with a pre-stroke mRS score of 0–1, a GCS score of 8–13, an NIHSS score of 10–30, and a stable hematoma volume of 30–100 ml, in order to reduce the risk of death or severe disability (mRS score of 5–6) [8];

the placement of an external ventricular drain (EVD) in patients with SICH and IVH and hydrocephalus contributing to impaired consciousness, with the aim of reducing mortality (expert recommendation); in patients with SICH and IVH, there is uncertainty regarding the effect of EVD placement, with or without lumbar drainage, on reducing the risk of death, dependency, or shunt dependency;

Consider EVD with intraventricular thrombolysis in SICH with IVH to reduce mortality, although there is uncertainty regarding the effect on patient dependency and shunt dependency;

Minimally invasive surgical removal of intraventricular hematoma in patients with SICH and IVH who require EVD to improve functional outcomes and reduce shunt dependency.

 

In patients with acute cerebellar hemorrhage, surgical removal of hematomas larger than 15 ml is recommended to improve survival.

 

5. Prevention and Treatment of Complications

In patients with SICH, the use of standardized protocols is recommended to reduce disability and mortality.

In patients with SICH, nurses in the emergency department and intensive care unit (ICU) should perform regular GCS assessments during the early hyperacute phase of care to evaluate changes in condition or level of consciousness.

In patients with SICH, frequent neurological examinations should be performed in the ICU and stroke unit for up to 72 hours after admission to detect early deterioration of neurological status.

In patients with acute SICH, a comprehensive care protocol is recommended to reduce mortality or disability, which includes:

timely intensive blood pressure reduction to achieve a target systolic blood pressure (SBP) < 140 mmHg in mild to moderate ICH within 1 hour of treatment initiation;

control of hyperglycemia to achieve values of 6.1–7.8 mmol/L as soon as possible after treatment initiation in patients without diabetes and 7.8–10 mmol/L in patients with diabetes, and maintaining these levels for 7 days from the onset of SICH to improve functional outcomes [9], while avoiding hypoglycemia;

treatment of fever with antipyretics to achieve a body temperature < 37.5 °C within 1 hour of treatment initiation and maintenance for 7 days following the onset of SICH to improve functional outcomes [9];

correction of abnormal anticoagulation using PCC in patients taking vitamin K antagonists to achieve an INR < 1.3 within 1 hour of treatment initiation and administration of specific antidotes in patients taking DOACs (see Chapter 3.2 Hemostatic Therapy for details).

 

In patients with acute SICH, the following may also be beneficial

not to implement general policies that restrict treatment or mandate do-not-resuscitate orders during the first 24 hours after admission, unless the patient expresses a clear wish or has a documented advance directive to limit life-sustaining treatment;

conducting routine screening for dysphagia and treating it to reduce disability and the risk of pneumonia;

Early consultation with a neurosurgeon to assess the need for surgical intervention, for example in patients with extensive subarachnoid hemorrhage (SAH), intraventricular hemorrhage (IVH), or infratentorial hemorrhage with expansive behavior.

 

Treatment with anticonvulsant medications

is not recommended for the primary prevention of acute symptomatic seizures, i.e., in patients without any seizure manifestations;

is recommended for patients with SICH who have impaired consciousness and confirmed seizure activity on EEG (to reduce morbidity) and for patients with clinically apparent seizures (to improve functional outcomes and prevent brain damage resulting from repeated prolonged seizures).

Treatment initiated following an acute symptomatic seizure (seizures) within the first 7 days after the onset of SICH should be discontinued after 4 weeks in patients who have not experienced further seizures, following individual assessment.

 

In patients with SICH and unexplained abnormal or fluctuating levels of consciousness (quantitative and/or qualitative) or neurological findings, or with suspected seizures, continuous EEG monitoring (≥ 24 h) is recommended to diagnose non-convulsive status epilepticus, electrographic seizures, and epileptiform discharges. If continuous monitoring is not available, it is advisable to perform at least repeated extended EEG examinations during the day (expert recommendation).

In patients with SICH, continuous ECG monitoring is recommended for the first 24–72 hours after admission to monitor for cardiac arrhythmias and new myocardial ischemia.

In patients with SICH, laboratory and radiological examinations should be performed to detect infection upon admission and during hospitalization.

In immobile patients with SICH

it is recommended to use compression stockings with intermittent pneumatic compression to prevent proximal deep vein thrombosis (DVT) for 30 days from the patient’s admission (or until discharge from the hospital or until the patient begins to walk independently, whichever occurs first);

following a follow-up imaging study that rules out progression of the hematoma size, LMWH at a prophylactic dose may be used 48–96 hours after the onset of SICH to prevent deep vein thrombosis;

in cases of high prothrombotic risk (due to comorbidities or prothrombotic medications), if intermittent pneumatic compression is not available or feasible, LMWH prophylaxis may be used to prevent venous thromboembolism;

and in cases of proximal DVT where anticoagulant therapy is currently contraindicated, temporary use of a caval filter is recommended as a bridging measure until anticoagulation can be initiated;

and in cases of proximal DVT or pulmonary embolism, delaying LMWH anticoagulation therapy by 1–2 weeks after the onset of ICH may be considered.

In patients with severe acute SICH and aggressive behavior, the use of invasive intracranial pressure (ICP) monitoring may be considered, preferably via intraventricular measurements with the option of cerebrospinal fluid drainage.

 

6. Secondary Prevention

In patients with a history of SICH, blood pressure control to a target of ≤130/80 mmHg is recommended to reduce the risk of recurrent stroke.

In patients with a history of SICH and nonvalvular atrial fibrillation

DOAC therapy may be considered after careful evaluation of the individual risk-benefit ratio (increased risk of ICH recurrence versus reduced risk of serious cardiovascular events);

who are considered unsuitable for long-term oral anticoagulation therapy, left atrial appendage occlusion with appropriate peri-procedural antithrombotic therapy may be considered to reduce the risk of thromboembolic events.

 

In patients with a history of SICH, it is recommended to consider resuming (if taken prior to ICH) or initiating antiplatelet therapy if there is an approved indication.

In patients with a history of SICH who are at high cardiovascular risk and have an indication for statin use, it is recommended to initiate statin therapy for both primary and secondary prevention after evaluating the individual risk-benefit ratio.

In patients with a history of SICH, regular long-term use of nonsteroidal anti-inflammatory drugs is potentially harmful due to an increased risk of SICH recurrence.

In patients with a history of SICH, lifestyle modifications—including limiting excessive alcohol consumption—are appropriate to lower blood pressure and reduce the risk of SICH recurrence, and supervised exercise and counseling should be utilized to improve functional recovery.

For patients with a history of SICH, it is advisable to provide caregivers with

psychosocial education to increase patients’ activity levels and participation and/or their quality of life,

practical support and training to improve patients’ balance while standing.

 

7. Prediction of Clinical Outcome and Care Goals

For patients with SICH, it is recommended to limit the use of scores for predicting the final clinical outcome to providing prognostic information; their use as the primary or sole method for predicting the final clinical outcome is not recommended, given the risk of a self-fulfilling prophecy.

For patients with SICH who cannot fully participate in decisions regarding their health status, a shared decision-making model between a court-appointed guardian and physicians is appropriate when deciding on the withdrawal of life-sustaining treatment.

 

8. Rehabilitation and Neurobehavioral Complications

Multidisciplinary rehabilitation, including regular team meetings and post-discharge care planning, should be provided for patients with SICH to improve functional outcomes and reduce morbidity and mortality.

In patients with moderate SICH, early rehabilitation initiated 24–48 hours after the onset of SICH (including training in activities of daily living, stretching, and functional task training) may be considered to improve functional outcomes and reduce mortality.

In patients with SICH, very early and intensive mobilization initiated within the first 24 hours is associated with a lower likelihood of achieving a good recovery.

In patients with SICH, screening for depression and anxiety (to identify them) and cognitive screening (to identify cognitive impairment and dementia) is recommended during the post-acute phase.

For patients with SICH and moderate to severe depression, comprehensive care including pharmacotherapy and psychotherapy is appropriate to alleviate symptoms of depression.

In patients with SICH and pre-existing or new mood disorders requiring pharmacotherapy, continuing or initiating treatment with selective serotonin reuptake inhibitors (SSRIs) may be beneficial.

For patients with SICH and cognitive impairment

, cognitive therapy is recommended;

treatment with cholinesterase inhibitors or memantine may be considered.

 

Patients with a history of SICH and their family members/caregivers should be informed, based on individual risk, about the possibility of developing epileptic seizures and their potential manifestations (expert recommendation).

9. Quality Control

To ensure continuous improvement in the quality of care, data on all hospitalized patients with SICH should be systematically entered into the RES-Q (Registry of Stroke Care Quality).

Entering data for all patients with SICH into RES-Q is essential for the objective evaluation of treatment organization and outcomes, to ensure transparency, and to support the implementation of recommended practices in clinical practice.

Data obtained through RES-Q will serve not only for the internal evaluation of individual centers but also as a basis for national and international comparisons and the development of health policy.

 

10. Discharge Report

The discharge summary for a patient with SICH must contain the minimum set of information defined in the recommended standard for discharge summaries of patients with stroke [10]. The minimum scope includes the following data:

primary diagnosis: hemorrhagic stroke,

lesion location,

results of initial brain and cerebral artery imaging,

date of onset,

clinical presentation,

Initial NIHSS score,

treatment: conservative (e.g., normalization of blood pressure and coagulation), neurosurgical procedure,

logistical data: e.g., DNT for initiation of antihypertensive therapy, time to achieve systolic blood pressure < 140 mmHg,

reversal of anticoagulation,

etiology,

outcome of follow-up brain imaging,

condition at discharge,

final NIHSS and mRS scores,

other: recommendations for outpatient examination, follow-up visits, and medication,

the location to which the patient was discharged.

 

Funding

R. Herzig was supported by Charles University (Cooperatio program, NEUR research area) and the Ministry of Health of the Czech Republic –⁠ RVO (FHNK, 00179906). M. Smrčka was supported by the Ministry of Health of the Czech Republic –⁠ RVO (FNBr, 65269705).

 

Conflict of Interest

The authors declare that they have no conflict of interest in connection with the subject of this work.