What is the initial management for a patient with intracranial bleeding?

Initial Management of Intracranial Bleeding

For patients with intracranial hemorrhage, immediate management should include rapid diagnosis with non-contrast CT, intensive blood pressure lowering to <140 mmHg within six hours of onset, reversal of any coagulopathy, and consideration for neurosurgical intervention based on clinical and radiographic factors. 1

Immediate Stabilization

• Airway, Breathing, Circulation: Secure airway if GCS ≤8 or deteriorating neurological status
• Blood Pressure Management:
  • Target systolic BP <140 mmHg within 6 hours of onset to reduce hematoma expansion risk
  • Approximately 38% of patients scanned within 3 hours experience hematoma expansion 1

Diagnostic Workup

• Non-contrast CT scan: Should be completed within 45 minutes of ED arrival to differentiate hemorrhagic from ischemic stroke 1
• CT angiography: Consider to evaluate for underlying vascular malformations or aneurysms 1

Management of Coagulopathy

For patients on anticoagulants, urgent reversal is critical:

• Vitamin K antagonists (e.g., warfarin):

  • Administer 4-factor PCC (25-50 IU/kg based on INR) with 10 mg IV vitamin K 2
  • PCC is superior to FFP for rapid INR correction and limiting hematoma expansion 2

• Direct oral anticoagulants:

  • For dabigatran: Administer idarucizumab (5g IV in two divided doses) 2
  • For factor Xa inhibitors (rivaroxaban, apixaban): Consider 4-factor PCC (50 U/kg) or activated PCC 2

• Antiplatelet agents:

  • Discontinue antiplatelet agents immediately 2
  • Platelet transfusion is not recommended unless neurosurgical intervention is planned 2

Management of Elevated Intracranial Pressure

• Osmotic therapy:

  • Mannitol 0.25-2 g/kg IV as a 15-25% solution over 30-60 minutes 3
  • Elevate head of bed 30 degrees to improve venous drainage
  • Avoid hypo-osmolar fluids (e.g., 5% dextrose in water) 2

• ICP monitoring: Consider in patients with GCS ≤8, clinical evidence of herniation, significant intraventricular hemorrhage, or hydrocephalus 1

• Ventricular drainage: Reasonable for patients with decreased level of consciousness, particularly with intraventricular hemorrhage 1

Surgical Management Considerations

• Indications for early surgery (within 96 hours):

  • GCS score 9-12
  • Hematomas extending to within 1 cm of cortical surface
  • Cerebellar hemorrhages ≥15 mL with brainstem compression or hydrocephalus 1

• Decompressive craniectomy: Consider for patients with coma, large hematomas, significant midline shift, or elevated ICP refractory to medical management 1

Prevention of Complications

• DVT prophylaxis:

  • Use intermittent pneumatic compression for immobile patients
  • Avoid graduated compression stockings 1
  • Consider pharmacological prophylaxis 24-48 hours after documented hematoma stability 1

• Seizure management:

  • Treat clinical seizures but routine prophylaxis is not recommended 1

• Temperature control:

  • Aggressively treat fever, though therapeutic cooling has not been shown to improve outcomes 1

Specialized Care

Management in a dedicated stroke or neurocritical care unit significantly improves outcomes 1. Continuous monitoring of vital signs, neurological status, and electrolytes is essential.

Pitfalls to Avoid

• Delayed reversal of anticoagulation: Can lead to hematoma expansion and worse outcomes
• Excessive fluid administration: May worsen cerebral edema
• Inadequate blood pressure control: Increases risk of hematoma expansion
• Delayed neurosurgical consultation: May miss window for life-saving intervention
• Overlooking hydrocephalus: Particularly with cerebellar or intraventricular hemorrhage

The prognosis depends mainly on hematoma size, location, and initial level of consciousness, with the majority of functional and cognitive recovery occurring weeks to months after discharge 1.