What are the initial steps for controlling bleeding in intracranial hemorrhage?

Initial Management of Intracranial Hemorrhage

Immediate intervention with surgery and/or interventional radiology is required for all patients with life-threatening intracranial hemorrhage to control bleeding. 1

Step-by-Step Algorithm for Bleeding Control in Intracranial Hemorrhage

1. Initial Assessment and Stabilization

• Perform rapid neurological evaluation (pupils + Glasgow Coma Scale motor score)
• Obtain immediate brain CT scan to determine severity and location of hemorrhage 1
• Stabilize airway, breathing, and circulation
• Optimize respiratory effort to prevent hypoxia 1

2. Immediate Hemorrhage Control Measures

• For exsanguinating patients with life-threatening hemorrhage:
  • Immediate surgical intervention and/or interventional radiology for bleeding control 1
  • Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during interventions 1
  • In cases of difficult bleeding control, lower blood pressure values may be tolerated only for the shortest possible time 1

3. Reversal of Coagulopathy (if present)

• Antiplatelet agents:

  • Discontinue all antiplatelet agents immediately 1
  • For patients requiring neurosurgical intervention:
    • Obtain platelet function testing if possible 1
    • Administer platelet transfusion for patients on aspirin or ADP inhibitors if platelet function is abnormal 1
    • Consider desmopressin (0.4 μg/kg IV) for patients on aspirin/COX-1 inhibitors or ADP receptor inhibitors 1
  • Avoid platelet transfusion if platelet function is normal or documented antiplatelet resistance exists 1

• Maintain coagulation parameters:

  • Keep platelet count >50,000/mm³ (higher for neurosurgical intervention) 1
  • Maintain PT/aPTT <1.5 normal control 1
  • Consider point-of-care testing (TEG, ROTEM) to assess and optimize coagulation function 1

4. Neurosurgical Intervention

• After control of life-threatening hemorrhage, all salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation and intervention 1
• Surgical evacuation may be beneficial for:
  • Cerebellar hemorrhages 1
  • Large cerebral hemisphere lesions with impending herniation 1
  • Consider early preperitoneal packing for ongoing hemodynamic instability 1

5. Management of Intracranial Pressure

• For patients at risk for intracranial hypertension:
  • Implement ICP monitoring 1
  • Maintain cerebral perfusion pressure ≥60 mmHg when ICP monitoring is available 1
  • In cases of cerebral herniation, use osmotherapy and/or temporary hypocapnia 1
  • Use a stepwise approach to elevated ICP, reserving more aggressive interventions for non-responders 1

Special Considerations

Blood Pressure Management

• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during interventions 1
• Control systemic hypertension to prevent rebleeding 1

Transfusion Thresholds

• Transfuse red blood cells for hemoglobin <7 g/dl during interventions 1
• Consider higher threshold for patients at risk (elderly, limited cardiovascular reserve) 1
• During massive transfusion protocol initiation, use RBCs/plasma/platelets at a 1:1:1 ratio 1

Respiratory Management

• Maintain PaO₂ between 60-100 mmHg 1
• Maintain PaCO₂ between 35-40 mmHg 1

Common Pitfalls and Caveats

• Delayed intervention: Early and aggressive management in the acute phase is critical for improved outcomes 2
• Inadequate reversal of coagulopathy: Complete reversal is essential before neurosurgical intervention
• Excessive blood pressure reduction: Maintaining adequate cerebral perfusion pressure is crucial to prevent secondary brain injury
• Failure to identify treatable causes: Thorough risk factor evaluation should be performed to identify and correct treatable causes of hemorrhage 1
• Inappropriate platelet transfusion: Avoid platelet transfusion for patients not undergoing neurosurgical procedures or those with normal platelet function 1

By following this structured approach to the initial management of intracranial hemorrhage, clinicians can optimize patient outcomes by minimizing secondary brain injury and preventing complications.