How is an intracranial (within the skull) hemorrhage (bleed) managed?

Management of Intracranial Hemorrhage

Intracranial hemorrhage requires immediate, aggressive intervention focused on preventing hematoma expansion, managing intracranial pressure, and reversing coagulopathy to improve mortality and functional outcomes.

Initial Assessment and Stabilization

• Immediate neuroimaging: Non-contrast CT scan is essential for diagnosis, determining hemorrhage location, size, and presence of mass effect 1
• Neurological monitoring: Hourly neurological examinations to detect early deterioration, particularly in cerebellar hemorrhages 1
• Blood pressure management:
  • Target systolic BP 120-150 mmHg to minimize mortality risk 2
  • Maintain cerebral perfusion pressure (CPP) between 50-70 mmHg 1

Management Based on Hemorrhage Type

Cerebellar Hemorrhage

• Surgical intervention criteria:
  • Hemorrhage ≥15 mL
  • Presence of brainstem compression
  • Obstructive hydrocephalus
  • Deteriorating neurological status 1
• External ventricular drainage (EVD) alone is insufficient and potentially harmful; should be combined with surgical decompression 1

Intraventricular Hemorrhage (IVH)

• Ventricular drainage is reasonable for patients with decreased level of consciousness 3
• Intraventricular thrombolysis: Administration of rt-PA in IVH appears to have a low complication rate but remains investigational (Class IIb, Level of Evidence B) 3

Intracerebral Hemorrhage (ICH)

• Surgical considerations:
  • Patients with hematomas extending to within 1 cm of cortical surface may benefit from surgery within 96 hours 3
  • Patients with lobar hemorrhages and GCS 9-12 may have better outcomes with surgery 3

Management of Coagulopathy

• Urgent reversal of anticoagulation is required for patients on anticoagulants prior to any surgical intervention 1
• For dabigatran-associated bleeding:
  • Administer idarucizumab (5g) for severe bleeding
  • If idarucizumab is unavailable, non-activated PCC (50 U/kg) or activated PCC (FEIBA 30-50 U/kg) can be used 3
  • Second administration of idarucizumab may be needed depending on clinical evolution 3

Management of Intracranial Pressure

• ICP monitoring is recommended for patients with GCS ≤8, clinical evidence of transtentorial herniation, significant IVH, or hydrocephalus 1
• Osmotic therapy:
  • Mannitol: 0.25-2 g/kg body weight as a 15-25% solution administered over 30-60 minutes 4
  • Pediatric dosing: 1-2 g/kg body weight or 30-60 g/m² over 30-60 minutes 4
  • Contraindicated in patients with:
    • Anuria due to severe renal disease
    • Severe pulmonary congestion or frank pulmonary edema
    • Active intracranial bleeding except during craniotomy
    • Severe dehydration
    • Progressive heart failure or pulmonary congestion 4

Prevention of Secondary Complications

• DVT prophylaxis: Initiate pharmacological prophylaxis (unfractionated or low-molecular-weight heparin) 24-48 hours after hematoma stability is documented 1
• Seizure management: Treat clinical seizures, but routine prophylaxis is not recommended 1
• Temperature management: Aggressively treat fever, although therapeutic cooling has not shown improved outcomes 5

Outcome Prediction and Prognosis

• Small hemorrhages (<15 mL) without brainstem compression or hydrocephalus may have reasonable outcomes with medical management 1
• Larger hemorrhages (≥15 mL) with brainstem compression or hydrocephalus have poor prognosis without surgical intervention 1
• Functional recovery occurs primarily weeks to months after discharge 5

Special Considerations

• Recommended primary outcomes for clinical trials evaluating hemostatic agents in intracranial hemorrhage include:
  1. Global patient-centered clinical outcome scale measured 30-180 days after the event
  2. Combined clinical and radiographic endpoint associating hemorrhage expansion with poor outcome at 24 hours or later
  3. Radiographic measure of hemorrhage expansion at 24 hours 3

By following this evidence-based approach to managing intracranial hemorrhage, clinicians can optimize patient outcomes through early intervention, appropriate surgical referral, and comprehensive critical care management.