What is the treatment for an intracranial hemorrhage (ICH) with midline shift?

From the Guidelines

The treatment for an intracranial bleed with midline shift requires immediate neurosurgical intervention, typically through a decompressive craniectomy or craniotomy to evacuate the hematoma and reduce intracranial pressure. This approach is supported by the most recent guidelines from the American Heart Association/American Stroke Association, which emphasize the importance of prompt intervention to reduce mortality and improve functional outcomes 1.

Initial Management

Initial management includes:

• Airway protection with rapid sequence intubation using medications like etomidate (0.3 mg/kg) and rocuronium (1.0 mg/kg)
• Mechanical ventilation targeting PaCO2 of 35-40 mmHg
• Osmotic therapy with mannitol (1.0-1.5 g/kg IV bolus) or hypertonic saline (3% solution at 0.5-1.0 mL/kg/hr) to reduce cerebral edema
• Seizure prophylaxis with levetiracetam (1000 mg IV loading dose, then 500 mg IV twice daily) for 7 days
• Careful management of blood pressure, maintaining systolic blood pressure below 140-160 mmHg using labetalol (10-20 mg IV boluses) or nicardipine (5-15 mg/hr) while avoiding hypotension

Reversal of Anticoagulation

Any anticoagulant or antiplatelet medications should be reversed immediately; for warfarin, administer prothrombin complex concentrate (25-50 units/kg) and vitamin K (10 mg IV); for DOACs, use specific reversal agents like idarucizumab for dabigatran or andexanet alfa for factor Xa inhibitors 1.

Minimally Invasive Surgery

Minimally invasive hematoma evacuation with endoscopic or stereotactic aspiration, with or without thrombolytic use, is safe and may be useful to reduce mortality, although the evidence for improvement in functional outcomes is lower 1.

Decompressive Craniectomy

Decompressive hemicraniectomy may be considered to reduce mortality in patients with supratentorial ICH who are in a coma, have large hematomas with midline shift, or have elevated ICP refractory to medical management 1.

These interventions are critical because midline shift indicates significant mass effect that can lead to herniation, brainstem compression, and death if not promptly addressed.

From the FDA Drug Label

Reduction of intracranial pressure and brain mass.

Adults: 0. 25 to 2 g/kg body weight as a 15% to 25% solution administered over a period of 30 to 60 minutes

Active intracranial bleeding except during craniotomy ( 4)

The treatment for intracranial bleed with midline shift using mannitol (IV) is contraindicated in cases of active intracranial bleeding except during craniotomy. However, in certain situations such as during craniotomy, mannitol may be administered to reduce intracranial pressure. The recommended dosage is 0.25 to 2 g/kg body weight as a 15% to 25% solution administered over a period of 30 to 60 minutes. Key considerations include:

• Contraindications: Active intracranial bleeding except during craniotomy
• Dosage: 0.25 to 2 g/kg body weight
• Administration: 15% to 25% solution over 30 to 60 minutes 2

From the Research

Treatment Options for Intracranial Bleed with Midline Shift

• The treatment of intracranial bleed with midline shift involves reducing intracranial pressure (ICP) and managing cerebral perfusion pressure (CPP) 3, 4.
• Hypertonic saline and mannitol are commonly used to reduce ICP in patients with intracranial hemorrhage (ICH) 3, 4, 5.
• A study comparing the effects of hypertonic saline and mannitol on ICP and CPP in patients with severe traumatic brain injury found that hypertonic saline was superior to mannitol in reducing the combined burden of intracranial hypertension and associated hypoperfusion 4.
• Another study found that hypertonic saline was as effective as mannitol in reducing ICP in a canine model of ICH, but may have a longer duration of action 3.

Management of Intracranial Hemorrhage

• The diagnosis and management of ICH involve history, physical examination, and noncontrast CT examination of the brain 6, 7.
• Blood pressure management, coagulopathy reversal, and intracranial pressure control are the mainstays of acute ICH treatment 7.
• Prevention of hematoma expansion and minimally invasive hematoma evacuation are promising therapeutic strategies under investigation 7.

Comparison of Hypertonic Saline and Mannitol

• A systematic review of randomized controlled trials comparing hypertonic saline with other ICP-lowering agents, including mannitol, found that the evidence for the effectiveness and safety of hypertonic saline was very low due to imprecision, indirectness, and risk of bias 5.
• The review suggested that hypertonic saline may be no better than mannitol in efficacy and safety in the long-term management of acute traumatic brain injury, but further research is needed to confirm this finding 5.