What interventions can help stop a brain bleed?

Management of Brain Bleeds (Intracerebral Hemorrhage)

Immediate surgical intervention or interventional radiology is required for all exsanguinating patients with life-threatening brain hemorrhage to control bleeding and prevent further damage.1

Initial Assessment and Diagnosis

• Rapid neuroimaging with CT or MRI is essential to distinguish intracerebral hemorrhage (ICH) from ischemic stroke 1
• Urgent neurological evaluation including pupils and Glasgow Coma Scale motor score should be performed 1
• CT angiography and contrast-enhanced CT may help identify patients at risk for hematoma expansion 1
• Additional vascular imaging (CT angiography, CT venography, MRA, MRV) should be considered to evaluate for underlying structural lesions when clinically or radiologically suspected 1

Immediate Management Priorities

Blood Pressure Control

• Maintain systolic blood pressure >100 mmHg or MAP >80 mmHg during interventions for life-threatening hemorrhage or emergency neurosurgery 1
• For patients with established ICH without brain injury, a target systolic BP of 80-100 mmHg may be appropriate until major bleeding is controlled 1
• For ICH management, target systolic BP should be 130-150 mmHg with smooth control and minimal fluctuations 2
• Antihypertensive agents such as nicardipine, urapidil, and labetalol are preferred due to their favorable cerebral hemodynamic profiles 2

Coagulopathy Reversal

1. For patients on vitamin K antagonists (warfarin):

   • Administer prothrombin complex concentrate (PCC) based on INR:

     INR	PCC Dose
     2-3.9	25 units/kg
     4-5.9	35 units/kg
     >6	50 units/kg

   • Administer intravenous vitamin K (5-10 mg) 2

2. For patients on direct oral anticoagulants:

   • Discontinue the medication immediately 1
   • Consider specific reversal agents if available

3. For patients on antiplatelet therapy:

   • Discontinue antiplatelet agents when ICH is present or suspected 1
   • Platelet transfusion is not recommended for patients who will not undergo neurosurgical procedures 1
   • For patients requiring neurosurgery:
     • Perform platelet function testing prior to transfusion if possible
     • Consider one single donor apheresis unit of platelets 1
     • Consider desmopressin (0.4 μg/kg IV) for aspirin/ADP receptor inhibitor-associated ICH 1

4. For patients who received thrombolytic agents:

   • Discontinue thrombolytic agents immediately 1
   • Consider cryoprecipitate (10 units initial dose) for symptomatic ICH within 24 hours of thrombolytic administration 1
   • If cryoprecipitate is contraindicated or unavailable, consider tranexamic acid (10-15 mg/kg IV over 20 min) or ε-aminocaproic acid (4-5 g IV) 1

Surgical Management

• All salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation and intervention after control of life-threatening hemorrhage 1
• Surgical evacuation is generally not recommended for most ICH cases based on age and location 2
• Cerebellar hemorrhages >3 cm or those causing brainstem compression or hydrocephalus should be surgically evacuated 1
• Ventricular drainage should be considered for hydrocephalus, especially in patients with decreased level of consciousness 1, 2
• External ventricular drain insertion is high-risk in patients requiring anticoagulation and should be carefully considered 1

Intracranial Pressure (ICP) Management

• Patients at risk for intracranial hypertension require ICP monitoring regardless of the need for emergency extra-cranial surgery 1
• For cerebral herniation awaiting or during emergency neurosurgery, use osmotherapy and/or temporary hypocapnia 1
• Maintain cerebral perfusion pressure (CPP) ≥60 mmHg when ICP monitoring is available 1
• For elevated ICP, use a stepwise approach, reserving more aggressive interventions for situations with no response to initial treatment 1
• Corticosteroids should NOT be administered for treatment of elevated ICP in ICH 2

Intraventricular Hemorrhage Management

• Intraventricular hemorrhage occurs in 45% of patients with spontaneous ICH 1
• Ventricular drainage as treatment for hydrocephalus is reasonable in patients with decreased level of consciousness 1
• Intraventricular administration of rt-PA in IVH is considered investigational 1

Hematologic Management

• Maintain platelet count >50,000/mm³ for patients requiring intervention for life-threatening systemic hemorrhage 1
• For emergency neurosurgery (including ICP probe insertion), a higher platelet count is advisable 1
• Maintain PT/aPTT <1.5 normal control during interventions for life-threatening hemorrhage or emergency neurosurgery 1
• Consider point-of-care tests (TEG, ROTEM) to assess and optimize coagulation function 1
• During massive transfusion protocol initiation, transfuse RBCs/plasma/platelets at a ratio of 1/1/1 1

Common Pitfalls to Avoid

• Delaying neuroimaging in suspected ICH cases
• Failing to reverse anticoagulation promptly in patients with ICH
• Aggressive blood pressure reduction that may compromise cerebral perfusion
• Administering corticosteroids for ICH-related edema
• Using hypotonic solutions like Ringer's lactate that can worsen brain edema 2
• Routine platelet transfusion for patients on antiplatelet therapy who will not undergo neurosurgery 1
• Delaying ventricular drainage in patients with hydrocephalus and decreased consciousness

Long-term Management

• Initiate mechanical thromboprophylaxis with intermittent pneumatic compression as soon as possible 2
• Consider pharmacological thromboprophylaxis within 24 hours after bleeding has been controlled 2
• Avoid inferior vena cava filters as routine thromboprophylaxis 2
• Target blood pressure control should be achieved within 3 months 2