FULL DISCLOSURE: I'm not a surgeon - I'm an emergency physician.  That said, and prior to calling the neurosurgeon for consult, I would order a ROTEM or TEG if available, and prepare to administer TXA if I could establish a "last well time" at less than three hours.  Also, could you clarify which type of ICH?  Epidural or expanding subdural hematoma would likely necessitate surgery.  "Sentinel hemorrhage" likewise, but perhaps n a more staged fashion. Are they hypertensive? (If this is EtOH withdrawal, I'm guessing "yes.")...

Thanks for a great question / scenario!

I would order a ROTEM or TEG if available, and prepare to administer TXA if

Thanks for putting these words in PROF. @Robert T Gerhardt. a pdf attached to explain this.

I could establish a "last well time" at less than three hours.

A friend says he was alright 30 minutes ago.

Also, could you clarify which type of ICH? Epidural or expanding subdural hematoma would likely necessitate surgery. INTRA 'CEREBRAL' HEMORRHAGE

"Sentinel hemorrhage" likewise, but perhaps n a more staged fashion.

Surprisingly no headache, no sentinel headache and the CT SCAN SHOWED the lobe affected to be pareital.

(Usually frontal lobe ICH have headache. )

Are they hypertensive?

Non hypertensive

(If this is EtOH withdrawal, I'm guessing "yes.")..

He has got early signs ONLY !

This question clarifies another point!

http://en.wikipedia.org/wiki/Alcoholism

Early signs

The risk of alcohol dependence begins at low levels of drinking and increases directly with both the volume of alcohol consumed and a pattern of drinking larger amounts on an occasion. Young adults are particularly at risk.[23]

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The patient is in the ER of the District General Hospital, CT = 30 cc invoving the Pareital lobe bleed. LORAZEPAM given. 10 minutes since the first seizure.

First, Secure airway due to seizure state and give medication to prevent from second seizure. The indications to perform surgery for clot evacuation: ICH clot >30cc and midline shift >5mm on CT scan. 80% case of spontaneous ICH is hipertensive form, so be careful if there is no hipertensive.

Very good PROF. Ronny Setiawan. He is maintaining good breathing without any tubes!

The anesthetist feels no need for any tubes in the ER. Just oxygen by mask.

GCS 14. ICH 30 cc, 4 mm midline shift ( not >30 cc). He is NON HYPERTENSIVE (from PMH). The anesthetist has been advised to maintain a NORMAL BP.  

Blood results are available: ALL normal. 

Patient accepted into the ITU of DISTRICT GENERAL HOSPITAL ( with no neurosurgery facility )

Would you THINK of operating (NOW 15 minutes since the admission) ? ( Neurosurgeon is 2 hours by ambulance from the DISTRICT GENERAL HOSPITAL) 

CT ANGIOGRAM done, not very clear, could be an AVM !

30 minutes since the original admission, Neurosurgeon busy in theater,

the General ITU consultant calls the NEURO ITU directly and after 5 minutes, the Neurology/stroke doctor accepts the patient and the patient is on the way to the QUARTER NARY NEURO center..the transfer will take 2 hours on the highway.......... an anaesthetist is accompanying the patient

Patient arrived at the QUARTER-NARY NEURO hospital. Neurology status quo,  CT SCAN REPEATED for the quality at the other hospital was poor due to image transfer! CT SCAN STATUS QUO!  GCS 14. ICH 30 cc, 4 mm midline shift ( not >30 cc).

I could establish a "last well time" at less than three hours. A friend says he was alright 30 minutes ago.

If you remember from 2 scrolls above, this *FRIEND* arrives and is excited (pretty much like a lemur) and starts querrying ::: when will YOU start BABY ASPIRIN 75 mg that HE is on, following a NON-OPERATED ICH coz, HE (the friend) is on it for some reason!

The READER can assume this is a PARALLEL Q?

http://www.medpagetoday.com/Cardiology/AcuteCoronarySyndrome/2532

http://www.nature.com/nrneurol/journal/v2/n9/full/ncpneuro0267.html (SEVERAL WEEKS AFTER says this article!!!!!!)