What is the management for intraparenchymal hemorrhage with midline shift and uncal herniation?

Management of Intraparenchymal Hemorrhage with Midline Shift and Uncal Herniation

Patients with intraparenchymal hemorrhage (ICH) presenting with uncal herniation and significant midline shift require immediate neurosurgical intervention, including decompressive craniectomy with or without hematoma evacuation, to reduce mortality.

Initial Emergency Management

Airway and Ventilation

• Secure airway with endotracheal intubation
• Ventilate with PaO2 ≥ 13 kPa and PaCO2 of 4.5-5.0 kPa 1
• For impending uncal herniation, temporary hyperventilation (PaCO2 not less than 4 kPa) is justified as a short-term measure 1

Positioning and ICP Management

• Position patient with 20-30° head-up tilt 1, 2
• Maintain cerebral perfusion pressure (CPP) of 50-70 mmHg 1
• Administer hyperosmolar therapy:
  • Mannitol (0.5 g/kg) or hypertonic saline (2 ml/kg of 3% saline) 1
  • Consider barbiturate therapy for refractory intracranial hypertension 1

Hemodynamic Management

• Target blood pressure: maintain adequate cerebral perfusion while avoiding hypertension
• Measure arterial blood pressure with transducer at the level of the tragus 1
• Manage hypertension with increased sedation and small boluses of labetalol 1
• Correct hypovolemia with isotonic fluids (0.9% saline) 1

Neurosurgical Intervention

Supratentorial ICH with Uncal Herniation

• Decompressive craniectomy (DC) with or without hematoma evacuation is indicated to reduce mortality in patients with large hematomas, significant midline shift, or elevated ICP refractory to medical management 1
• Surgery should be performed urgently, as earlier intervention (within 8 hours of hemorrhage) has been associated with improved outcomes 1
• For patients in coma with uncal herniation, DC may be life-saving 1, 3

Cerebellar Hemorrhage

• Patients with cerebellar hemorrhage who have brainstem compression and/or hydrocephalus should undergo surgical removal of the hemorrhage as soon as possible 1
• Initial treatment with ventricular drainage alone is not recommended for cerebellar hemorrhage 1

Surgical Approach Considerations

• Minimally invasive surgical techniques may be considered but their effectiveness remains uncertain 1
• For uncal herniation specifically, aggressive temporal lobectomy has shown better survival rates and functional outcomes in some studies compared to conventional approaches 4

Post-Surgical Management

ICP Monitoring and Management

• Consider ICP monitoring in patients with GCS ≤8, clinical evidence of transtentorial herniation, or significant IVH/hydrocephalus 1
• Direct ICP treatment at the underlying cause (hydrocephalus or mass effect) 1
• Monitor for rebound edema and delayed complications

Seizure Management

• Administer antiepileptic drugs for clinical seizures 1
• Consider prophylactic antiepileptic therapy, particularly in patients with lobar hemorrhage 1
• Be vigilant for nonconvulsive seizures, which occur in 28% of ICH patients and are associated with increased midline shift 5

Temperature Management

• Avoid hyperthermia, which worsens outcomes in brain injury 1
• Consider targeted temperature management to reduce cerebral edema

Prognostic Factors and Monitoring

Factors Associated with Poor Outcomes

• Low GCS on presentation and postoperatively 3
• Presence of uncal herniation 3
• Significant postoperative midline shift 3
• Diabetes mellitus 3
• Unequal pupils 3

Follow-up Imaging

• Perform follow-up neuroimaging to assess resolution of mass effect and midline shift
• Monitor for development of hydrocephalus, which predicts poor outcome 1

Caveats and Pitfalls

• Do not delay neurosurgical intervention in patients with uncal herniation, as this is a neurological emergency 2
• Avoid lumbar puncture in patients with cerebral mass effect due to risk of worsening herniation 2
• Recognize that withdrawal of care decisions made too early may adversely affect outcomes, as many prediction models do not account for the impact of aggressive interventions 1
• Be aware that seizures after ICH may be nonconvulsive and require EEG monitoring 5
• Understand that ultra-early craniotomy (within 4 hours) may be associated with increased risk of rebleeding 1

The evidence strongly supports immediate neurosurgical intervention for patients with ICH presenting with uncal herniation and midline shift, as this represents a life-threatening emergency requiring rapid decompression to prevent fatal outcomes.