What are the appropriate discharge instructions for a patient after an intracranial hemorrhage?

Discharge Instructions After Intracranial Hemorrhage

Patients discharged after an intracranial hemorrhage must receive clear written instructions about symptoms of delayed hemorrhage, including severe or worsening headache, repeated vomiting, increasing confusion, seizures, weakness or numbness, vision changes, difficulty speaking, and loss of consciousness—with explicit instructions to return immediately if any occur. 1

Essential Components of Discharge Instructions

Warning Signs Requiring Immediate Return

The 2023 ACEP guidelines explicitly recommend providing discharge instructions that include symptoms of rare, delayed hemorrhage 1. Based on evidence-based factors predictive of hemorrhage progression, patients and caregivers must be instructed to watch for:

• Severe or worsening headache that doesn't improve with prescribed pain medication
• Repeated vomiting (more than once)
• Increasing confusion or disorientation
• Seizure activity (new onset convulsions or shaking)
• Weakness or numbness in face, arms, or legs (especially one-sided)
• Vision changes (blurred vision, double vision, or vision loss)
• Difficulty speaking or slurred speech
• Loss of consciousness or difficulty staying awake
• Unsteady walking or loss of balance

2, 3

Medication Management Instructions

For patients on anticoagulants or antiplatelet agents:

• Discontinue anticoagulants and antiplatelet medications during the acute period for at least 1-2 weeks after hemorrhage 4, 5
• The decision to restart antithrombotic therapy depends on the risk of subsequent arterial or venous thromboembolism versus risk of recurrent ICH 4
• Outpatient referral for assessment of both fall risk and risk/benefit of anticoagulation therapy should be arranged 1
• For patients with comparatively lower risk of cerebral infarction (e.g., atrial fibrillation without prior ischemic stroke) and higher risk of amyloid angiopathy (elderly patients with lobar ICH), antiplatelet agents may be considered instead of restarting warfarin 4
• If restarting warfarin is necessary in very high-risk thromboembolism patients, it may be reasonable to restart at 7-10 days after onset of the original ICH 4

Home Observation Requirements

Critical caveat: Patients requiring ongoing physical or cognitive assistance should have someone who can assist them with following discharge care instructions and provide a safe environment during recovery 1. This is particularly important given that delayed ICH, while rare (occurring in up to approximately 5% of patients), can be clinically significant 1.

Follow-up Arrangements

• Neurology or neurosurgery follow-up should be scheduled within 1-2 weeks
• Primary care follow-up for medication reconciliation and fall risk assessment
• Outpatient referral for anticoagulation risk/benefit reassessment 1

Special Populations

Patients on Anticoagulants/Antiplatelet Agents

For patients with mild traumatic brain injury on anticoagulants or antiplatelet medications who had an initial head CT without hemorrhage:

• Do not routinely admit or observe if they are at baseline neurologic examination and have no other criteria for extended monitoring 1
• Do not routinely perform repeat imaging if at baseline neurologic examination 1
• However, clear discharge instructions with return precautions are warranted given the potential for delayed ICH 1

Elderly Patients on Aspirin

Important caveat: Elderly patients (≥65 years) on low-dose aspirin may require greater caution, as studies suggest a 4% rate of delayed ICH in this population, with some requiring neurosurgical intervention 1. Consider longer observation or lower threshold for repeat imaging in this subgroup.

Documentation and Communication

Discharge instructions should be:

• Written at an appropriate reading level (aim for 6th-8th grade reading level) 2
• Provided in both written and verbal format
• Reviewed with both patient and caregiver to ensure understanding
• Include specific contact numbers for emergency return or questions
• Document that instructions were provided and understood in the medical record

Common Pitfalls to Avoid

1. Premature prognostication: Avoid limiting life-sustaining treatments based solely on baseline severity scales in the acute period 6
2. Inadequate caregiver assessment: Don't discharge patients who lack adequate home supervision, especially those on anticoagulants 1
3. Vague instructions: Avoid generic "return if symptoms worsen" language—be specific about which symptoms warrant immediate return 2
4. Failure to address anticoagulation: Must explicitly address when/if to restart anticoagulation and arrange appropriate follow-up 4, 5