Management: –

1. Manage any airway, breathing, and circulatory insufficiencies requiring urgent treatment.
2. Arrange an immediate review by a neurosurgeon to assess whether the patient will benefit from neurosurgery.
3. Consider rapid lowering of blood pressure (BP) for patients with ICH who have a systolic BP of 150 to 220 mmHg aiming to reach a systolic BP of 140 mmHg or lower while ensuring that the magnitude drop does not exceed 60 mmHg within 1 hour of starting treatment. Only if has all of the following criteria: –
   • Present within 6 hours of symptom onset
   • Do not have: an underlying structural cause (e.g., tumour, arteriovenous malformation, or aneurysm); GCS score <6 or have a massive haematoma with a poor expected prognosis.
   • Are not going to have early neurosurgery to evacuate the haematoma.
4. Urgently reverse abnormalities of clotting, particularly in patients taking anticoagulants.
   • Warfarin — give a combination of prothrombin complex concentrate (4-factor) and intravenous vitamin K.
   • Dabigatran — reverse with idarucizumab
   • Factor Xa inhibitor — treat with prothrombin complex concentrate (4-factor)
5. Consider monitoring the patient for signs of elevated intracranial pressure (ICP) and treatment if any of the following is present:​​
   • Glasgow Coma Scale score ≤8 that is presumed related to haematoma mass effect
   • Clinical evidence of transtentorial herniation
     • Uncal herniation causes a fixed and dilated ipsilateral pupil due to compression of the ipsilateral oculomotor nerve.
     • The earliest signs of central herniation are behavioural changes, confusion/drowsiness, and small pupils with minimal reaction to light. Later on, Cushing reflex may be present with high blood pressure and reflexive bradycardia.
   • Significant intraventricular haemorrhage or hydrocephalus.
6. Consult immediately with a neurologist if the patient has uncontrolled or recurrent seizures, or status epilepticus. In clinical practice, levetiracetam and sodium valproate are commonly used.
7. Give intermittent pneumatic compression within 3 days of admission for the prevention of deep venous thrombosis and pulmonary embolism in immobile patients.