From the Guidelines
To rule out a brain bleed in a patient, you should immediately order a non-contrast CT scan of the head, which is the gold standard initial diagnostic test, as recommended by the most recent guidelines 1. This imaging modality can quickly detect acute hemorrhage, appearing as hyperdense (bright white) areas within the brain tissue. For patients with a negative CT but strong clinical suspicion, follow up with an MRI, which is more sensitive for detecting small hemorrhages, especially in the posterior fossa or those that are subacute, as suggested by the American Heart Association/American Stroke Association guidelines 1. Some key points to consider when evaluating a patient for a brain bleed include:
- The clinical presentation, including symptoms such as severe headache, nausea/vomiting, and altered mental status
- The importance of prompt imaging, with non-contrast CT being the initial test of choice
- The potential need for additional testing, such as MRI or lumbar puncture, in cases where the diagnosis is unclear
- The importance of close monitoring and prompt intervention, including neurosurgical consultation and blood pressure management, in cases where a brain bleed is confirmed. It is also important to note that the management of brain bleeds is a medical emergency, and prompt diagnosis and treatment are essential to improve outcomes, as highlighted by the guidelines for the management of spontaneous intracerebral hemorrhage 1. In terms of specific imaging recommendations, the guidelines suggest that CT angiography (CTA) may be useful in identifying vascular abnormalities, such as aneurysms or arteriovenous malformations, and that MRI or CT venography may be necessary to evaluate for cerebral vein thrombosis 1. Overall, the key to ruling out a brain bleed is to approach the diagnosis with a high index of suspicion, to use prompt and appropriate imaging, and to be prepared to intervene quickly in cases where a brain bleed is confirmed, as recommended by the guidelines for the management of aneurysmal subarachnoid hemorrhage 1.
From the FDA Drug Label
Active intracranial bleeding except during craniotomy. The FDA drug label does not answer the question.
From the Research
Ruling Out Brain Bleed
To rule out a brain bleed in a patient, the following steps can be taken:
- Conduct a noncontrast computed tomographic (CT) scan of the brain, as it is the main imaging modality recommended for the initial emergency evaluation of acute stroke 2
- If the CT scan is negative, consider alternative imaging techniques such as gradient echo ("susceptibility-weighted") magnetic resonance imaging sequences to detect an acute intracerebral hemorrhage 2
- If the patient is taking anticoagulant or antiplatelet agents, consider administering vitamin K, fresh frozen plasma, and platelet transfusion to arrest progression of intracranial hemorrhage 3
- Use prothrombin complex concentrate (PCC) for rapid and effective reversal of warfarin in life-threatening neurosurgical emergencies 4, 5
- Consider out-of-hours CT head scans, as they can lead to an immediate change in a patient's management, including ruling out intracranial bleed requiring urgent neurosurgical intervention 6
Diagnostic Considerations
- CT scans may not always detect intracerebral hemorrhage, especially in the early stages 2
- Magnetic resonance imaging (MRI) may be more sensitive than CT scans in detecting acute intracerebral hemorrhage 2
- The use of PCC can rapidly reverse anticoagulation and allow for urgent neurosurgical care 5
Treatment Considerations
- Appropriate administration of vitamin K, fresh-frozen plasma, and platelets can successfully arrest progression of traumatic intracranial hemorrhages in patients taking anticoagulant/antiplatelet agents 3
- PCC can be used to immediately reverse anticoagulation and allow for urgent neurosurgical intervention 4, 5