What is the initial management of a suspected brain bleed?

From the Guidelines

The initial management of a suspected brain bleed should prioritize rapid assessment, stabilization, and prompt medical intervention, with a focus on securing the airway, breathing, and circulation, and obtaining immediate neuroimaging, preferably a non-contrast CT scan of the head, to confirm the diagnosis and determine the type and extent of bleeding, as recommended by the Canadian Stroke Best Practice Recommendations 2015 1.

Key Considerations

• Secure the airway, breathing, and circulation (ABC) while maintaining cervical spine precautions if trauma is involved
• Elevate the head of the bed to 30 degrees to reduce intracranial pressure
• Obtain immediate neuroimaging, preferably a non-contrast CT scan of the head, to confirm the diagnosis and determine the type and extent of bleeding
• Monitor vital signs closely, with particular attention to blood pressure control—hypertension should be treated cautiously to maintain cerebral perfusion while preventing hematoma expansion
• Reverse any coagulopathy promptly; for patients on warfarin, administer vitamin K (10 mg IV) and prothrombin complex concentrate; for direct oral anticoagulants, specific reversal agents may be needed (idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors)

Atypical Presentations

• Some patients may present with atypical symptoms, such as seizures, confusion, or altered mental status, which can make diagnosis more challenging
• A high index of suspicion is necessary to diagnose brain bleeds, especially in patients with a history of trauma or anticoagulant use
• The American Heart Association/American Stroke Association guidelines recommend that patients with suspected aneurysmal subarachnoid hemorrhage (aSAH) should be treated as a medical emergency and evaluated immediately by physicians with expertise in stroke management 1

Management

• Patients with aSAH should undergo vascular imaging of the brain to investigate the cause of the hemorrhage, with high-quality CTA initially preferable to catheter angiography, as recommended by the Canadian Stroke Best Practice Recommendations 2015 1
• The severity of SAH patients should be determined using a validated scale, such as the World Federation of Neurological Surgeons (WFNS), GCS, Hunt and Hess scale (H&H), NIHSS, and the Fisher Scale
• Patients with SAH should be managed in centers with neurosurgical expertise that treat aneurysms regularly using endovascular and surgical techniques
• Nimodipine should be administered to all patients with aSAH, as recommended by the American Heart Association/American Stroke Association guidelines 1

From the FDA Drug Label

The precise mechanism of action of nimodipine in humans is unknown Although the clinical studies described below demonstrate a favorable effect of nimodipine on the severity of neurological deficits caused by cerebral vasospasm following SAH, there is no arteriographic evidence that the drug either prevents or relieves the spasm of these arteries Nimodipine has been shown, in 4 randomized, double-blind, placebo-controlled trials, to reduce the severity of neurological deficits resulting from vasospasm in patients who have had a recent subarachnoid hemorrhage (SAH).

The initial management of a suspected brain bleed involves administering nimodipine orally, with a recommended dose of 60 mg (two 30 mg capsules) every 4 hours for 21 consecutive days 2.

• The treatment should commence as soon as possible within 96 hours of the onset of subarachnoid hemorrhage.
• Patients with severely disturbed liver function may require a reduced dosage of one 30 mg capsule every 4 hours with close monitoring of blood pressure and heart rate 2.
• Grapefruit juice should be avoided due to potential drug interactions 2.
• If the patient is unconscious or unable to swallow, the contents of the capsule can be extracted and administered through a nasogastric tube 2.

From the Research

Initial Management of Suspected Brain Bleed

The initial management of a suspected brain bleed involves several key steps:

• Prompt medical attention is crucial in cases of suspected brain bleed, as timely intervention can significantly impact outcomes 3
• Computerized tomography (CT) scans are commonly used to diagnose brain hemorrhage and guide medical and surgical management 3
• Intensive medical therapy, including monitoring of intracranial pressure (ICP) and management of blood pressure, may improve outcomes in patients with brain hemorrhage 3
• Surgical removal of the hematoma may be indicated in certain cases, such as lobar and putaminal hemorrhages, or large cerebellar hemorrhages with significant brain stem compression 3

Atypical Presentations of Brain Bleeds

Atypical presentations of brain bleeds can include:

• Delayed cerebral ischemia (DCI), which can occur after aneurysmal subarachnoid hemorrhage (aSAH) and is a major contributor to poor outcomes 4, 5, 6
• Cerebral vasospasm, which can lead to decreased cerebral blood flow and ischemic damage 4, 5, 6
• Changes in cerebrovascular autoregulation, which can affect cerebral blood flow and oxygenation 7

Treatment Options

Treatment options for brain bleeds include:

• Nimodipine, a calcium antagonist that can reduce the incidence of ischemic complications after aSAH 4, 5, 6
• Intravenous or oral administration of nimodipine, which may have similar efficacy in preventing delayed ischemic neurological deficits (DINDs) and cerebral vasospasm 6
• Intra-arterial administration of nimodipine, which may have a more pronounced effect on cerebrovascular autoregulation and brain tissue oxygenation compared to intravenous administration 7