Summary

2022 AHA/ASA guideline for management of spontaneous (nontraumatic, non-structural) intracerebral hemorrhage in adults, updating the 2015 version. Key updates include refined acute BP targets emphasizing smooth sustained control, expanded anticoagulation reversal recommendations (4F-PCC, idarucizumab, andexanet alfa), evidence against prophylactic corticosteroids/hyperosmolar therapy/platelet transfusions/antiseizure prophylaxis, support for minimally invasive hematoma evacuation to reduce mortality, and broader criteria for cerebellar ICH surgery (now including volume >15 mL).

Key Recommendations

Obtain noncontrast CT or MRI immediately to confirm ICH and estimate volume (ABC/2); CTA within first hours can identify spot sign and macrovascular causes.
For mild-moderate ICH with SBP 150–220 mm Hg, lower SBP to a target of 130–140 mm Hg with smooth, sustained control; avoid SBP <130 mm Hg and large BP variability.
For VKA-associated ICH with INR ≥2, give 4-factor PCC (preferred over FFP) plus IV vitamin K 5–10 mg.
For dabigatran-associated ICH, give idarucizumab 5 g IV; if unavailable, consider activated PCC; hemodialysis may help.
For factor Xa inhibitor–associated ICH (apixaban, rivaroxaban, edoxaban), give andexanet alfa or 4F-PCC.
Do not give prophylactic platelet transfusions for antiplatelet-associated ICH unless emergency neurosurgery is planned (aspirin + craniotomy).
Avoid prophylactic corticosteroids, continuous hyperosmolar therapy, and prophylactic antiseizure medications; treat only clinical or electrographic seizures.
Start intermittent pneumatic compression on day of admission for VTE prophylaxis; graduated compression stockings alone are ineffective; add prophylactic UFH/LMWH 24–48 h after hemorrhage stability.
Place EVD for hydrocephalus with depressed consciousness; add intraventricular alteplase for obstructive IVH to reduce mortality (CLEAR III).
Perform surgical evacuation for cerebellar ICH with volume >15 mL, neurologic deterioration, brainstem compression, or hydrocephalus.
Consider minimally invasive hematoma evacuation (endoscopic or stereotactic ± thrombolytic) for supratentorial ICH to reduce mortality; decompressive hemicraniectomy may be life-saving in comatose patients with large hematomas or refractory ICP.
Do not use early DNAR orders or baseline severity scores alone to limit care; provide full guideline-concordant care for at least the first day, ideally longer, and use shared decision-making.

Thresholds & Doses

Target SBP 130–140 mm Hg for acute ICH with presenting SBP 150–220 mm Hg; avoid SBP <130 mm Hg.
Maintain CPP 60–70 mm Hg in patients with large ICH (>30 mL) or elevated ICP.
4F-PCC dose for VKA reversal: 25–50 IU/kg (INR/weight-based) or fixed 1500 U; lower 10–20 IU/kg if INR 1.3–2.0.
IV vitamin K 5–10 mg with PCC for VKA-associated ICH.
Idarucizumab 5 g IV (two 2.5-g boluses) for dabigatran reversal.
Activated charcoal useful within 2 h (dabigatran/apixaban) up to 8 h (rivaroxaban) of last dose.
Protamine IV infusion ≤50 mg per 10 min to reverse UFH.
Treat hypoglycemia at glucose <40–60 mg/dL; treat hyperglycemia targeting <180 mg/dL; avoid intensive control 80–110 mg/dL.
ICH volume thresholds: cerebellar >15 mL → surgery; supratentorial >30 mL or GCS <8 → consider neurosurgical evaluation; MIS trials enrolled ≥20–30 mL.
GCS ≤8 → consider intubation and ICP monitoring; treat ICP >22 mm Hg.
Continuous EEG monitoring ≥24 h (≥48 h if comatose) when seizures suspected.
Initiate prophylactic UFH/LMWH 24–48 h after ICH onset once hemorrhage stable; use IPC from admission day.
Long-term BP target ≤130/80 mm Hg for secondary prevention.
Resume anticoagulation after ICH: ~14 days for LVAD, ~6 days for mechanical valves (case-by-case), ~7–8 weeks for AF.
ICH recurrence risk: ~1.1%/y non-CAA vs ~7.4%/y CAA-related.
Hyperacute HE: ~26% within 1 h, ~12% by 20 h, rare after 24 h.
STICH late time threshold: surgery beyond 62 h associated with worse outcomes.

Citations

Top 10 Take-Home Messages — overview of major updates including BP variability, anticoagulant reversal agents, MIS evacuation, cerebellar surgery criteria.
Section 5.1 (Acute BP Lowering) — INTERACT2/ATACH-2 derived SBP target 130–140 mm Hg.
Section 5.2.1 (Anticoagulant-Related Hemorrhage) and Figure 2 — 4F-PCC for VKA, idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors.
Section 5.2.2 (Antiplatelet-Related Hemorrhage) — PATCH trial; avoid platelet transfusion outside emergent surgery.
Section 5.3.3 (Thromboprophylaxis) — CLOTS 3, IPC over stockings, timing of pharmacologic prophylaxis.
Section 5.5 (Neuroinvasive Monitoring) — EVD indications; no benefit/harm from steroids and prophylactic mannitol.
Sections 6.1.1–6.1.4 (Surgical Evacuation) — MISTIE III, CLEAR III, STICH I/II, cerebellar ICH >15 mL surgical criterion.
Section 9.1.2 (BP Management) — long-term target ≤130/80 mm Hg based on PROGRESS, SPS3, 2017 hypertension guideline.