Additionally, elevated C-reactive protein levels, lower serum levels of low-density lipoprotein cholesterol (LDL-C), and lower total cholesterol have been linked to a risk of neurologic deterioration and mortality in patients with acute ICH [146,147]. Imaging risk factors Initial ICH volume The ICH volume on initial head computed tomography (CT) scan at admission may be a particularly important prognostic indicator [99,107,111,148]. In a study of 188 patients, the initial ICH volume was associated with 30-day mortality rate. Among patients with a GCS score 9, the probability of death by 30 days was 19 percent when the ICH volume was 30 mL and 75 percent when the ICH volume was 60 mL [99]. The method for calculating ICH volume from head CT is discussed separately. (See "Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis", section on 'Estimating hemorrhage volume'.) ICH location Patients with ICH located in the infratentorial brainstem or cerebellar regions have worse prognosis than those with supratentorial ICH [149]. Intraventricular extension Intraventricular and subarachnoid extension of ICH may be present on initial evaluation or occur subsequently. Data from a number of studies suggest that extension of blood into the ventricles and/or subarachnoid space is an independent predictor of poor outcome in patients with spontaneous ICH [107,150-156]. One of the largest of these reports evaluated 406 patients with ICH, 45 percent of whom had https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 23/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate intraventricular extension of hemorrhage [154]. After controlling for age and ICH volume, a poor outcome at discharge (defined as an mRS score of 4 to 6 ( table 9)) was significantly more likely in patients with intraventricular hemorrhage than in those without intraventricular hemorrhage (OR 2.25, 95% CI 1.40-3.64). Intraventricular hemorrhage is discussed in detail separately. (See "Intraventricular hemorrhage".) Hematoma shape and features ICH shape irregularity and heterogeneity on head CT and the spot sign on CT angiography suggest ongoing bleeding or risk of hematoma expansion and have been associated with poor functional outcome ( image 1 and image 2) [157]. These are discussed separately. (See "Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis", section on 'Predicting hemorrhage expansion'.) Hematoma growth Hematoma growth, particularly within the first 24 hours, is also an independent predictor of mortality and poor outcome [112,157,158]. In a meta-analysis of 218 patients with spontaneous ICH who had a head CT scan within three hours of onset and follow-up head CT within 24 hours, for each 10 percent increase in hematoma volume, patients were 5 percent more likely to die (hazard ratio 1.05, 95% CI 1.03-1.08) and 16 percent less likely to have a good outcome as measured by the modified Rankin scale (cumulative OR 0.84, 95% CI 0.75-0.92) [25]. Risk factors for hematoma enlargement (eg, contrast extravasation or "spot sign" on CT angiography, hemorrhage volume on baseline imaging, antithrombotic therapy) are discussed separately. (See "Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis", section on 'Predicting hemorrhage expansion'.) Other factors Other imaging such as extensive white matter lesions on CT or magnetic resonance imaging (MRI) have been associated with poor outcome and mortality after ICH in various studies [159-161]. Some studies have found that a significant number of patients with ICH have acute ischemic lesions on diffusion-weighted MRI sequence that are not contiguous to the hematoma [162]. The implication for these findings for prognosis is as yet undefined, although one study found that the presence of these lesions was associated with increased odds of death and disability [163]. (See "Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis", section on 'Mechanisms of brain injury'.) https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 24/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate Clinical prediction scores Multiple clinical scores have been developed to help approximate the risk of 30-day mortality or likelihood of good functional recovery for patients with acute ICH. These clinical scoring systems can be used in the acute setting to assist clinicians, patients, and caregivers gauge the expected severity of the ICH. They should be used along with overall clinical judgement, incorporating patient values and preferences to guide treatment decisions or limitations of care in the acute settings. Patients with acute ICH should be offered full treatment, and new limitations of care should be delayed at least until the second hospital day for most patients. (See 'Initial aggressive care' above.) ICH score A simple six-point clinical and radiographic grading scale called the ICH score has been devised to predict 30-day mortality after ICH [149]. This scale incorporates several clinical components that may be independent predictors of outcome ( table 10). The ICH score is determined by adding the score from each component as follows: GCS ( - - - table 7) score at presentation 3 to 4 (= 2 points) 5 to 12 (= 1 point) 13 to 15 (= 0 points) ICH volume on initial imaging - 3 30 cm (= 1 point) 3 <30 cm (= 0 points) Intraventricular extension of ICH - Present (= 1 point) Absent (= 0 points) Infratentorial origin of ICH - Yes (= 1 point) No (= 0 points) Age - - 80 (= 1 point) <80 (= 0 points) Thirty-day mortality rates increased steadily with ICH score. The mortality rates were: ICH score 1 (13 percent) ICH score 2 (26 percent) https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 25/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate ICH score 3 (72 percent) ICH score 4 (97 percent) ICH score 5 (100 percent) No patient with an ICH score of 0 died, and none had a score of 6 in the initial cohort. The ICH score has been validated by multiple analyses [164-166]. A modified ICH score using the National Institutes of Health Stroke Scale (NIHSS) score ( table 11) in place of the GCS score performed similar to the original ICH score for mortality prediction but was a better predictor of outcome in one study [164]. FUNC score The FUNC score ( table 12) rates prognosis for good functional (neurologic) outcome at 90 days using an 11-point scale [167]. Components include age, ICH volume, ICH location, GCS score, and history of prior cognitive impairment. The proportion of patients who achieved functional independence increased steadily with FUNC score [167]. In the study cohort, functional independence rates were: FUNC scores 0 to 4 (none) FUNC scores 5 to 7 (13 percent) FUNC score 8 (42 percent) FUNC scores 9 to 10 (66 percent) FUNC score 11 (82 percent) These results have also been independently validated [168]. One study found that GCS score at presentation alone is a useful predictor of 30-day mortality [169]. However, the GCS score is insufficient for clinical prognostication after ICH because some patients with acute ICH and reversible causes to stupor may have a low GCS score at admission but still achieve a good functional outcome. SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Stroke in adults".) INFORMATION FOR PATIENTS https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 26/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." th th The Basics patient education pieces are written in plain language, at the 5 to 6 grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more th th sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.) Basics topic (see "Patient education: Hemorrhagic stroke (The Basics)") Beyond the Basics topic (see "Patient education: Hemorrhagic stroke treatment (Beyond the Basics)") SUMMARY AND RECOMMENDATIONS Goals of acute care The goals of initial treatment include preventing hemorrhage extension, monitoring for and managing elevated intracranial pressure, and managing other neurologic and medical complications ( table 1). We generally provide initial aggressive care to patients with acute ICH and delay prognostication or enacting new limitations in care for at least the first day. (See 'Introduction' above and 'Triage' above.) Management of antithrombotic medications For patients with acute ICH, all anticoagulant and antiplatelet drugs should be discontinued acutely. Medications to reverse the effects of anticoagulant drugs should be given immediately. (See 'Management of acute bleeding' above.) Blood pressure management For patients with acute ICH who present with systolic blood pressure (SBP) between 150 and 220 mmHg, we suggest rapid lowering of SBP to a target of 140 mmHg, provided the patient remains clinically stable (Grade 2C). (See 'Blood pressure management' above.) For patients with acute ICH who present with SBP >220 mmHg, we suggest rapid lowering of SBP to <220 mmHg. Thereafter, the blood pressure is gradually reduced (over a period of https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 27/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate hours) to a target range of 140 to 160 mmHg, provided the patient remains clinically stable (Grade 2C). Management of ICP Preventive measures should be enacted in all patients with ICH to mitigate risk of morbidity associated with elevated intracranial pressure (ICP) ( algorithm 1). (See 'Intracranial pressure management' above.) Osmotic therapy For patients who have severe signs or symptoms of elevated ICP or for those with milder symptoms that progress despite initial measures, we use osmotic therapy with either hypertonic saline or mannitol. (See 'Osmotic therapy' above.) Ventricular drainage Ventricular drainage of cerebrospinal fluid with an external ventricular drain can help reduce elevated ICP for selected patients with hydrocephalus, particularly when associated with a decreased level of consciousness. (See 'Cerebrospinal fluid drainage for obstructive hydrocephalus' above.) Surgical approaches The role of surgery in patients with acute ICH varies with the site of the bleed. The indications for evacuation of a cerebellar hematoma depend on the ICH size and location, the time since onset, and the clinical status of the patient. Patients presenting acutely with a large cerebellar hemorrhage and brainstem compression will typically require urgent surgical decompression of the cerebellum with craniectomy and hematoma evacuation. Other patients with small, subacute cerebellar hematomas that do not exert mass effect on the brainstem may be managed medically with close monitoring. (See 'Cerebellar hemorrhage' above.) For patients selected for surgical decompression of a cerebellar hematoma, we suggest craniectomy and hematoma evacuation rather than ventriculostomy without posterior fossa decompression (Grade 2C). External drainage alone may create the theoretical risk of upward herniation of the cerebellar mass. We reserve surgical therapy for patients with life-threatening mass effect from supratentorial ICH, individualizing treatment decisions based on assessments of prognosis with and without surgical therapy. (See 'Supratentorial hemorrhage' above.) Seizure management For patients with acute ICH who have a seizure, immediate intravenous antiseizure medication treatment should be initiated to reduce the risk of a recurrent seizure. For patients with acute ICH who do not have a seizure, we do not start antiseizure medication prophylaxis. (See 'Seizure management' above.) https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 28/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate Medical complications of acute ICH General medical management issues include (see 'Prevention and management of medical complications' above): Prevention of aspiration (see "Complications of stroke: An overview", section on 'Dysphagia' and "Risk factors and prevention of hospital-acquired and ventilator- associated pneumonia in adults", section on 'Preventing aspiration') Prevention of venous thromboembolism (see "Prevention and treatment of venous thromboembolism in patients with acute stroke", section on 'Approach in intracerebral hemorrhage' and "Prevention of venous thromboembolic disease in acutely ill hospitalized medical adults") Prevention of pressure-induced skin injury (see "Prevention of pressure-induced skin and soft tissue injury") Isotonic fluid replacement (see 'Intracranial pressure management' above and "Maintenance and replacement fluid therapy in adults") Fever management (see "Initial assessment and management of acute stroke", section on 'Fever') Management of hyperglycemia and hypoglycemia (see "Initial assessment and management of acute stroke", section on 'Hyperglycemia' and "Glycemic control in critically ill adult and pediatric patients") Avoiding routine gastric acid suppression (see "Complications of stroke: An overview", section on 'Gastrointestinal bleeding' and "Stress ulcers in the intensive care unit: Diagnosis, management, and prevention", section on 'High-risk patients') Prognosis The 30-day mortality rate from ICH ranges from 32 to 52 percent but differs by clinical and imaging features as well as underlying etiology. (See 'Early prognosis' above.) Use of UpToDate is subject to the Terms of Use. REFERENCES 1. Abid KA, Vail A, Patel HC, et al. Which factors influence decisions to transfer and treat patients with acute intracerebral haemorrhage and which are associated with prognosis? A retrospective cohort study. BMJ Open 2013; 3:e003684. 2. Ciccone A, Celani MG, Chiaramonte R, et al. Continuous versus intermittent physiological https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 29/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate monitoring for acute stroke. Cochrane Database Syst Rev 2013; :CD008444. 3. Langhorne P, Fearon P, Ronning OM, et al. Stroke unit care benefits patients with intracerebral hemorrhage: systematic review and meta-analysis. Stroke 2013; 44:3044. 4. Gross BA, Jankowitz BT, Friedlander RM. Cerebral Intraparenchymal Hemorrhage: A Review. JAMA 2019; 321:1295. 5. Greenberg SM, Ziai WC, Cordonnier C, et al. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282. 6. Ma L, Hu X, Song L, et al. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet 2023. 7. Maas MB, Rosenberg NF, Kosteva AR, et al. Surveillance neuroimaging and neurologic examinations affect care for intracerebral hemorrhage. Neurology 2013; 81:107. 8. Hemphill JC 3rd, White DB. Clinical nihilism in neuroemergencies. Emerg Med Clin North Am 2009; 27:27. 9. Becker KJ, Baxter AB, Cohen WA, et al. Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology 2001; 56:766. 10. Alkhachroum A, Bustillo AJ, Asdaghi N, et al. Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired Consciousness. Stroke 2021; 52:3891. 11. Zahuranec DB, Morgenstern LB, S nchez BN, et al. Do-not-resuscitate orders and predictive models after intracerebral hemorrhage. Neurology 2010; 75:626. 12. Qureshi AI, Mendelow AD, Hanley DF. Intracerebral haemorrhage. Lancet 2009; 373:1632. 13. Al-Shahi Salman R, Law ZK, Bath PM, et al. Haemostatic therapies for acute spontaneous intracerebral haemorrhage. Cochrane Database Syst Rev 2018; 4:CD005951. 14. Baharoglu MI, Cordonnier C, Al-Shahi Salman R, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet 2016; 387:2605. 15. Mayer SA, Brun NC, Begtrup K, et al. Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med 2008; 358:2127. 16. O'Connell KA, Wood JJ, Wise RP, et al. Thromboembolic adverse events after use of recombinant human coagulation factor VIIa. JAMA 2006; 295:293. 17. Diringer MN, Skolnick BE, Mayer SA, et al. Risk of thromboembolic events in controlled trials of rFVIIa in spontaneous intracerebral hemorrhage. Stroke 2008; 39:850. https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 30/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate 18. Mayer SA, Brun NC, Broderick J, et al. Safety and feasibility of recombinant factor VIIa for acute intracerebral hemorrhage. Stroke 2005; 36:74. 19. Mayer SA, Brun NC, Begtrup K, et al. Recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med 2005; 352:777. 20. Sugg RM, Gonzales NR, Matherne DE, et al. Myocardial injury in patients with intracerebral hemorrhage treated with recombinant factor VIIa. Neurology 2006; 67:1053. 21. Subramaniam S, Demchuk AM, Watson T, et al. Unexpected posthemorrhagic hydrocephalus in patients treated with rFVIIa. Neurology 2006; 67:1096. 22. Sprigg N, Flaherty K, Appleton JP, et al. Tranexamic acid for hyperacute primary IntraCerebral Haemorrhage (TICH-2): an international randomised, placebo-controlled, phase 3 superiority trial. Lancet 2018; 391:2107. 23. Meretoja A, Yassi N, Wu TY, et al. Tranexamic acid in patients with intracerebral haemorrhage (STOP-AUST): a multicentre, randomised, placebo-controlled, phase 2 trial. Lancet Neurol 2020; 19:980. 24. Brott T, Broderick J, Kothari R, et al. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke 1997; 28:1. 25. Davis SM, Broderick J, Hennerici M, et al. Hematoma growth is a determinant of mortality and poor outcome after intracerebral hemorrhage. Neurology 2006; 66:1175. 26. Zhang Y, Reilly KH, Tong W, et al. Blood pressure and clinical outcome among patients with acute stroke in Inner Mongolia, China. J Hypertens 2008; 26:1446. 27. Divani AA, Liu X, Di Napoli M, et al. Blood Pressure Variability Predicts Poor In-Hospital Outcome in Spontaneous Intracerebral Hemorrhage. Stroke 2019; 50:2023. 28. Manning L, Hirakawa Y, Arima H, et al. Blood pressure variability and outcome after acute intracerebral haemorrhage: a post-hoc analysis of INTERACT2, a randomised controlled trial. Lancet Neurol 2014; 13:364. 29. Ohwaki K, Yano E, Nagashima H, et al. Blood pressure management in acute intracerebral hemorrhage: relationship between elevated blood pressure and hematoma enlargement. Stroke 2004; 35:1364. 30. Sakamoto Y, Koga M, Yamagami H, et al. Systolic blood pressure after intravenous antihypertensive treatment and clinical outcomes in hyperacute intracerebral hemorrhage: the stroke acute management with urgent risk-factor assessment and improvement- intracerebral hemorrhage study. Stroke 2013; 44:1846. 31. Qureshi AI, Palesch YY, Barsan WG, et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med 2016; 375:1033. https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 31/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate 32. Anderson CS, Huang Y, Arima H, et al. Effects of early intensive blood pressure-lowering treatment on the growth of hematoma and perihematomal edema in acute intracerebral hemorrhage: the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT). Stroke 2010; 41:307. 33. Qureshi AI, Mohammad YM, Yahia AM, et al. A prospective multicenter study to evaluate the feasibility and safety of aggressive antihypertensive treatment in patients with acute intracerebral hemorrhage. J Intensive Care Med 2005; 20:34. 34. Qureshi AI, Palesch YY, Martin R, et al. Effect of systolic blood pressure reduction on hematoma expansion, perihematomal edema, and 3-month outcome among patients with intracerebral hemorrhage: results from the antihypertensive treatment of acute cerebral hemorrhage study. Arch Neurol 2010; 67:570. 35. Butcher KS, Jeerakathil T, Hill M, et al. The Intracerebral Hemorrhage Acutely Decreasing Arterial Pressure Trial. Stroke 2013; 44:620. 36. Gould B, McCourt R, Asdaghi N, et al. Autoregulation of cerebral blood flow is preserved in primary intracerebral hemorrhage. Stroke 2013; 44:1726. 37. Butcher KS, Baird T, MacGregor L, et al. Perihematomal edema in primary intracerebral hemorrhage is plasma derived. Stroke 2004; 35:1879. 38. Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med 2013; 368:2355. 39. Qureshi AI, Palesch YY, Foster LD, et al. Blood Pressure-Attained Analysis of ATACH 2 Trial. Stroke 2018; 49:1412. 40. Moullaali TJ, Wang X, Martin RH, et al. Blood pressure control and clinical outcomes in acute intracerebral haemorrhage: a preplanned pooled analysis of individual participant data. Lancet Neurol 2019; 18:857. 41. Steiner T, Al-Shahi Salman R, Beer R, et al. European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke 2014; 9:840. 42. Cordonnier C, Demchuk A, Ziai W, Anderson CS. Intracerebral haemorrhage: current approaches to acute management. Lancet 2018; 392:1257. 43. Patterson DF, Ho ML, Leavitt JA, et al. Comparison of Ocular Ultrasonography and Magnetic Resonance Imaging for Detection of Increased Intracranial Pressure. Front Neurol 2018; 9:278. 44. Ohle R, McIsaac SM, Woo MY, Perry JJ. Sonography of the Optic Nerve Sheath Diameter for Detection of Raised Intracranial Pressure Compared to Computed Tomography: A Systematic Review and Meta-analysis. J Ultrasound Med 2015; 34:1285. https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 32/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate 45. Singleton J, Dagan A, Edlow JA, Hoffmann B. Real-time optic nerve sheath diameter reduction measured with bedside ultrasound after therapeutic lumbar puncture in a patient with idiopathic intracranial hypertension. Am J Emerg Med 2015; 33:860.e5. 46. Poungvarin N, Bhoopat W, Viriyavejakul A, et al. Effects of dexamethasone in primary supratentorial intracerebral hemorrhage. N Engl J Med 1987; 316:1229. 47. Stevens RD, Shoykhet M, Cadena R. Emergency Neurological Life Support: Intracranial Hypertension and Herniation. Neurocrit Care 2015; 23 Suppl 2:S76. 48. Shah M, Birnbaum L, Rasmussen J, et al. Effect of Hyperosmolar Therapy on Outcome Following Spontaneous Intracerebral Hemorrhage: Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study. J Stroke Cerebrovasc Dis 2018; 27:1061. 49. Kamel H, Navi BB, Nakagawa K, et al. Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Crit Care Med 2011; 39:554. 50. Mortazavi MM, Romeo AK, Deep A, et al. Hypertonic saline for treating raised intracranial pressure: literature review with meta-analysis. J Neurosurg 2012; 116:210. 51. Berger-Pelleiter E, mond M, Lauzier F, et al. Hypertonic saline in severe traumatic brain injury: a systematic review and meta-analysis of randomized controlled trials. CJEM 2016; 18:112. 52. Cook AM, Morgan Jones G, Hawryluk GWJ, et al. Guidelines for the Acute Treatment of Cerebral Edema in Neurocritical Care Patients. Neurocrit Care 2020; 32:647. 53. Helbok R, Kurtz P, Schmidt JM, et al. Effect of mannitol on brain metabolism and tissue oxygenation in severe haemorrhagic stroke. J Neurol Neurosurg Psychiatry 2011; 82:378. 54. Ropper AH. Management of raised intracranial pressure and hyperosmolar therapy. Pract Neurol 2014; 14:152. 55. Dorman HR, Sondheimer JH, Cadnapaphornchai P. Mannitol-induced acute renal failure. Medicine (Baltimore) 1990; 69:153. 56. Da Pian R, Bazzan A, Pasqualin A. Surgical versus medical treatment of spontaneous posterior fossa haematomas: a cooperative study on 205 cases. Neurol Res 1984; 6:145. 57. van Loon J, Van Calenbergh F, Goffin J, Plets C. Controversies in the management of spontaneous cerebellar haemorrhage. A consecutive series of 49 cases and review of the literature. Acta Neurochir (Wien) 1993; 122:187. 58. Kuramatsu JB, Biffi A, Gerner ST, et al. Association of Surgical Hematoma Evacuation vs Conservative Treatment With Functional Outcome in Patients With Cerebellar Intracerebral Hemorrhage. JAMA 2019; 322:1392. https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 33/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate 59. Hersh EH, Gologorsky Y, Chartrain AG, et al. Minimally Invasive Surgery for Intracerebral Hemorrhage. Curr Neurol Neurosci Rep 2018; 18:34. 60. Hanley DF, Thompson RE, Muschelli J, et al. Safety and efficacy of minimally invasive surgery plus alteplase in intracerebral haemorrhage evacuation (MISTIE): a randomised, controlled, open-label, phase 2 trial. Lancet Neurol 2016; 15:1228. 61. Scaggiante J, Zhang X, Mocco J, Kellner CP. Minimally Invasive Surgery for Intracerebral Hemorrhage. Stroke 2018; 49:2612. 62. Hanley DF, Thompson RE, Rosenblum M, et al. Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial. Lancet 2019; 393:1021. 63. Mendelow AD, Gregson BA, Fernandes HM, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet 2005; 365:387. 64. Nakano T, Ohkuma H. Surgery versus conservative treatment for intracerebral haemorrhage is there an end to the long controversy? Lancet 2005; 365:361. 65. Brown DL, Morgenstern LB. Stopping the bleeding in intracerebral hemorrhage. N Engl J Med 2005; 352:828. 66. Broderick JP. The STICH trial: what does it tell us and where do we go from here? Stroke 2005; 36:1619. 67. Mendelow AD, Gregson BA, Rowan EN, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet 2013; 382:397. 68. Cruz-Flores S. Early surgery and initial conservative therapy did not differ for outcomes in lobar intracerebral hematomas. Ann Intern Med 2013; 159:JC11. 69. Gautschi OP, Schaller K. Surgery or conservative therapy for cerebral haemorrhage? Lancet 2013; 382:377. 70. Freeman WD. Management of Intracranial Pressure. Continuum (Minneap Minn) 2015; 21:1299. 71. Schwab S, Spranger M, Schwarz S, Hacke W. Barbiturate coma in severe hemispheric stroke: useful or obsolete? Neurology 1997; 48:1608. 72. Sung CY, Chu NS. Epileptic seizures in thrombotic stroke. J Neurol 1990; 237:166. 73. Bladin CF, Alexandrov AV, Bellavance A, et al. Seizures after stroke: a prospective multicenter study. Arch Neurol 2000; 57:1617. https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 34/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate 74. De Herdt V, Dumont F, H non H, et al. Early seizures in intracerebral hemorrhage: incidence, associated factors, and outcome. Neurology 2011; 77:1794. 75. Vespa PM, O'Phelan K, Shah M, et al. Acute seizures after intracerebral hemorrhage: a factor in progressive midline shift and outcome. Neurology 2003; 60:1441. 76. Graham NS, Crichton S, Koutroumanidis M, et al. Incidence and associations of poststroke epilepsy: the prospective South London Stroke Register. Stroke 2013; 44:605. 77. Passero S, Rocchi R, Rossi S, et al. Seizures after spontaneous supratentorial intracerebral hemorrhage. Epilepsia 2002; 43:1175. 78. Peter-Derex L, Philippeau F, Garnier P, et al. Safety and efficacy of prophylactic levetiracetam for prevention of epileptic seizures in the acute phase of intracerebral haemorrhage (PEACH): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Neurol 2022; 21:781. 79. Angriman F, Tirupakuzhi Vijayaraghavan BK, Dragoi L, et al. Antiepileptic Drugs to Prevent Seizures After Spontaneous Intracerebral Hemorrhage. Stroke 2019; 50:1095. 80. Gilad R, Boaz M, Dabby R, et al. Are post intracerebral hemorrhage seizures prevented by anti-epileptic treatment? Epilepsy Res 2011; 95:227. 81. Naidech AM, Garg RK, Liebling S, et al. Anticonvulsant use and outcomes after intracerebral hemorrhage. Stroke 2009; 40:3810. 82. Mess SR, Sansing LH, Cucchiara BL, et al. Prophylactic antiepileptic drug use is associated with poor outcome following ICH. Neurocrit Care 2009; 11:38. 83. Zhang Y, Wang Y, Ji R, et al. In-hospital complications affect short-term and long-term mortality in ICH: a prospective cohort study. Stroke Vasc Neurol 2021; 6:201. 84. Koivunen RJ, Haapaniemi E, Satop J, et al. Medical acute complications of intracerebral hemorrhage in young adults. Stroke Res Treat 2015; 2015:357696. 85. Balami JS, Buchan AM. Complications of intracerebral haemorrhage. Lancet Neurol 2012; 11:101. 86. Hemphill JC 3rd, Greenberg SM, Anderson CS, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015; 46:2032. 87. Chi G, Lee JJ, Sheng S, et al. Systematic Review and Meta-Analysis of Thromboprophylaxis with Heparins Following Intracerebral Hemorrhage. Thromb Haemost 2022; 122:1159. 88. Honig A, Michael S, Eliahou R, Leker RR. Central fever in patients with spontaneous intracerebral hemorrhage: predicting factors and impact on outcome. BMC Neurol 2015; 15:6. https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 35/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate 89. Greer DM, Funk SE, Reaven NL, et al. Impact of fever on outcome in patients with stroke and neurologic injury: a comprehensive meta-analysis. Stroke 2008; 39:3029. 90. Westendorp WF, Vermeij JD, Zock E, et al. The Preventive Antibiotics in Stroke Study (PASS): a pragmatic randomised open-label masked endpoint clinical trial. Lancet 2015; 385:1519. 91. Fogelholm R, Murros K, Rissanen A, Avikainen S. Long term survival after primary intracerebral haemorrhage: a retrospective population based study. J Neurol Neurosurg Psychiatry 2005; 76:1534. 92. Flaherty ML, Haverbusch M, Sekar P, et al. Long-term mortality after intracerebral hemorrhage. Neurology 2006; 66:1182. 93. Sacco S, Marini C, Toni D, et al. Incidence and 10-year survival of intracerebral hemorrhage in a population-based registry. Stroke 2009; 40:394. 94. Zia E, Engstr m G, Svensson PJ, et al. Three-year survival and stroke recurrence rates in patients with primary intracerebral hemorrhage. Stroke 2009; 40:3567. 95. van Asch CJ, Luitse MJ, Rinkel GJ, et al. Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis. Lancet Neurol 2010; 9:167. 96. Gonz lez-P rez A, Gaist D, Wallander MA, et al. Mortality after hemorrhagic stroke: data from general practice (The Health Improvement Network). Neurology 2013; 81:559. 97. Moulin S, Cordonnier C. Prognosis and Outcome of Intracerebral Haemorrhage. Front Neurol Neurosci 2015; 37:182. 98. Fernando SM, Qureshi D, Talarico R, et al. Intracerebral Hemorrhage Incidence, Mortality, and Association With Oral Anticoagulation Use: A Population Study. Stroke 2021; 52:1673. 99. Broderick JP, Brott TG, Duldner JE, et al. Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality. Stroke 1993; 24:987. 100. Franke CL, van Swieten JC, Algra A, van Gijn J. Prognostic factors in patients with intracerebral haematoma. J Neurol Neurosurg Psychiatry 1992; 55:653. 101. Jolink WM, Klijn CJ, Brouwers PJ, et al. Time trends in incidence, case fatality, and mortality of intracerebral hemorrhage. Neurology 2015; 85:1318. 102. B jot Y, Blanc C, Delpont B, et al. Increasing early ambulation disability in spontaneous intracerebral hemorrhage survivors. Neurology 2018; 90:e2017. 103. Kase CS, Williams JP, Wyatt DA, Mohr JP. Lobar intracerebral hematomas: clinical and CT analysis of 22 cases. Neurology 1982; 32:1146. 104. Massaro AR, Sacco RL, Mohr JP, et al. Clinical discriminators of lobar and deep hemorrhages: the Stroke Data Bank. Neurology 1991; 41:1881. https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 36/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate 105. van Beijnum J, Lovelock CE, Cordonnier C, et al. Outcome after spontaneous and arteriovenous malformation-related intracerebral haemorrhage: population-based studies. Brain 2009; 132:537. 106. Beslow LA, Licht DJ, Smith SE, et al. Predictors of outcome in childhood intracerebral hemorrhage: a prospective consecutive cohort study. Stroke 2010; 41:313. 107. Lo WD, Hajek C, Pappa C, et al. Outcomes in children with hemorrhagic stroke. JAMA Neurol 2013; 70:66. 108. Murthy SB, Merkler AE, Omran SS, et al. Outcomes after intracerebral hemorrhage from arteriovenous malformations. Neurology 2017; 88:1882. 109. Poon MT, Fonville AF, Al-Shahi Salman R. Long-term prognosis after intracerebral haemorrhage: systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2014; 85:660. 110. Bar B, Hemphill JC 3rd. Charlson comorbidity index adjustment in intracerebral hemorrhage. Stroke 2011; 42:2944. 111. Woo D, Comeau ME, Venema SU, et al. Risk Factors Associated With Mortality and Neurologic Disability After Intracerebral Hemorrhage in a Racially and Ethnically Diverse Cohort. JAMA Netw Open 2022; 5:e221103. 112. Rodriguez-Luna D, Rubiera M, Ribo M, et al. Ultraearly hematoma growth predicts poor outcome after acute intracerebral hemorrhage. Neurology 2011; 77:1599. 113. Mayer SA, Sacco RL, Shi T, Mohr JP. Neurologic deterioration in noncomatose patients with supratentorial intracerebral hemorrhage. Neurology 1994; 44:1379. 114. Leira R, D valos A, Silva Y, et al. Early neurologic deterioration in intracerebral hemorrhage: predictors and associated factors. Neurology 2004; 63:461. 115. Hemphill JC 3rd, Newman J, Zhao S, Johnston SC. Hospital usage of early do-not-resuscitate orders and outcome after intracerebral hemorrhage. Stroke 2004; 35:1130. 116. Zahuranec DB, Brown DL, Lisabeth LD, et al. Early care limitations independently predict mortality after intracerebral hemorrhage. Neurology 2007; 68:1651. 117. Creutzfeldt CJ, Becker KJ, Weinstein JR, et al. Do-not-attempt-resuscitation orders and prognostic models for intraparenchymal hemorrhage. Crit Care Med 2011; 39:158. 118. Parry-Jones AR, Sammut-Powell C, Paroutoglou K, et al. An Intracerebral Hemorrhage Care Bundle Is Associated with Lower Case Fatality. Ann Neurol 2019; 86:495. 119. Cucchiara B, Messe S, Sansing L, et al. Hematoma growth in oral anticoagulant related intracerebral hemorrhage. Stroke 2008; 39:2993. https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-and-prognosis/print 37/79 7/5/23, 12:24 PM Spontaneous intracerebral hemorrhage: Acute treatment and prognosis - UpToDate 120. Falcone GJ, Biffi A, Brouwers HB, et al. Predictors of hematoma volume in deep and lobar supratentorial intracerebral hemorrhage. JAMA Neurol 2013; 70:988. 121. Flaherty ML, Tao H, Haverbusch M, et al. Warfarin use leads to larger intracerebral hematomas. Neurology 2008; 71:1084. 122. Saloheimo P, Ahonen M, Juvela S, et al. Regular aspirin-use preceding the onset of primary intracerebral hemorrhage is an independent predictor for death. Stroke 2006; 37:129. 123. Rosand J, Eckman MH, Knudsen KA, et al. The effect of warfarin and intensity of anticoagulation on outcome of intracerebral hemorrhage. Arch Intern Med 2004; 164:880. 124. Xian Y, Zhang S, Inohara T, et al. Clinical Characteristics and Outcomes Associated With Oral Anticoagulant Use Among Patients Hospitalized With Intracerebral Hemorrhage. JAMA Netw Open 2021; 4:e2037438. 125. Dowlatshahi D, Butcher KS, Asdaghi N, et al. Poor prognosis in warfarin-associated intracranial hemorrhage despite anticoagulation reversal. Stroke 2012; 43:1812. 126. Wilson D, Charidimou A, Shakeshaft C, et al. Volume and functional outcome of intracerebral hemorrhage according to oral anticoagulant type. Neurology 2016; 86:360. 127. Takahashi H, Jimbo Y, Takano H, et al. Intracerebral Hematoma Occurring During Warfarin Versus Non-Vitamin K Antagonist Oral Anticoagulant Therapy. Am J Cardiol 2016; 118:222. 128. Wilson D, Seiffge DJ, Traenka C, et al. Outcome of intracerebral hemorrhage associated with different oral anticoagulants. Neurology 2017; 88:1693. 129. Gerner ST, Kuramatsu JB, Sembill JA, et al. Characteristics in Non-Vitamin K Antagonist Oral Anticoagulant-Related Intracerebral Hemorrhage. Stroke 2019; 50:1392. 130. Toyoda K, Okada Y, Minematsu K, et al. Antiplatelet therapy contributes to acute deterioration of intracerebral hemorrhage. Neurology 2005; 65:1000. 131. Naidech AM, Bernstein RA, Levasseur K, et al. Platelet activity and outcome after intracerebral hemorrhage. Ann Neurol 2009; 65:352. 132. Naidech AM, Jovanovic B, Liebling S, et al. Reduced platelet activity is associated with early clot growth and worse 3-month outcome after intracerebral hemorrhage. Stroke 2009; 40:2398.