What are the assessment and treatment guidelines for patients presenting with brain bleeds?

From the Guidelines

Assessment and treatment of brain bleeds requires rapid evaluation and intervention, with a focus on blood pressure management, reversal of anticoagulation, and neurosurgical intervention as needed, to minimize morbidity, mortality, and improve quality of life. Initial assessment should include a thorough neurological examination, determination of Glasgow Coma Scale score, and urgent neuroimaging with CT or MRI to identify the location, size, and cause of the hemorrhage.

• Key considerations in management include:
  • Blood pressure management with targets generally below 140/90 mmHg for most hemorrhages, using medications like labetalol, nicardipine, or clevidipine, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
  • Reversal of anticoagulation should be immediate using specific agents, such as prothrombin complex concentrate and vitamin K for warfarin, or specific reversal agents like idarucizumab for dabigatran or andexanet alfa for factor Xa inhibitors, as outlined in the guideline for reversal of antithrombotics in intracerebral hemorrhage 1.
  • Seizure prophylaxis with levetiracetam may be considered for patients with lobar hemorrhages.
  • Neurosurgical intervention, including external ventricular drainage for hydrocephalus or hematoma evacuation, should be considered based on hemorrhage location, size, and neurological status.
  • Intracranial pressure monitoring and management are essential for patients with large hemorrhages or declining consciousness, maintaining cerebral perfusion pressure above 60-70 mmHg, as emphasized in the WSES consensus conference guidelines for monitoring and management of severe adult traumatic brain injury patients with polytrauma in the first 24 hours 1. These interventions are time-sensitive as brain tissue is highly vulnerable to secondary injury from increased pressure, inflammation, and biochemical cascades following the initial hemorrhage.

From the FDA Drug Label

The dosage, concentration and rate of administration depend on the age, weight and condition of the patient. 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 Oral nimodipine therapy should commence as soon as possible within 96 hours of the onset of subarachnoid hemorrhage.

The assessment and treatment guidelines for patients presenting with brain bleeds include:

• Reduction of intracranial pressure: using mannitol injection, with a recommended dosage of 0.25 to 2 g/kg body weight as a 15% to 25% solution administered over a period of 30 to 60 minutes 2
• Oral nimodipine therapy: commencing as soon as possible within 96 hours of the onset of subarachnoid hemorrhage, with a recommended oral dose of 60 mg (two 30 mg capsules) every 4 hours for 21 consecutive days 3
• Monitoring: of cardiovascular status, electrolyte levels, and renal function to avoid complications such as fluid and electrolyte imbalances, and renal failure 2
• Contraindications: active intracranial bleeding except during craniotomy, severe pulmonary congestion or frank pulmonary edema, and well-established anuria due to severe renal disease 2

From the Research

Assessment Guidelines for Brain Bleeds

The assessment and treatment of patients presenting with brain bleeds involve several key considerations, including:

• The cause of the hemorrhage, with hypertension accounting for about half of cases, and other causes including tumors, aneurysms, and vascular malformations 4
• The location of the hemorrhage, with hypertensive brain hemorrhage occurring in the deep gray nuclei of the hemispheres, the cerebellum, and the pons, resulting in specific clinical syndromes depending on the location 4
• The use of computerized tomography (CT) scans to diagnose brain hemorrhage and guide medical and surgical management 4

Treatment Guidelines

Treatment options for brain bleeds include:

• Intensive medical therapy guided by clinical status and continuous monitoring of intracranial pressure (ICP) 4
• Surgical removal of the hematoma, which is indicated in lobar and putaminal hemorrhages when the patient is deteriorating in spite of vigorous medical therapy, as well as in large cerebellar hemorrhages or those that result in significant brain stem compression 4
• The use of nimodipine, a selective calcium channel blocker, which has been shown to improve neurological recovery, functional capability, and recovery of consciousness in patients with subarachnoid and intracerebral hemorrhage 5
• The use of levetiracetam, an antiepileptic drug, which has been associated with improved cognitive outcome in patients with intracerebral hemorrhage compared to phenytoin 6

Recommendations for Research and Treatment

Recent studies have highlighted the importance of:

• Controlling for key factors that influence outcomes in anticoagulant-related intracerebral bleeds, including hematoma expansion, time-dependent factors, and computed tomography angiography spot sign 7
• Developing guidelines for the treatment of adults with severe head trauma, including initial assessment, evaluation, and pre-hospital treatment, as well as systemic and cerebral monitoring 8
• Standardizing methods of neurological evaluation and CT scan classification and scheduling to improve communications and clinical decisions in the multidisciplinary setting of management 8