What is the management of interhemispheric hemorrhage?

Management of Interhemispheric Hemorrhage

The management of interhemispheric hemorrhage requires rapid diagnosis through neuroimaging, aggressive early intervention, and a coordinated approach involving neurology, neurosurgery, and critical care specialists to reduce morbidity and mortality. 1

Initial Assessment and Stabilization

• Prehospital Management:

  • Provide ventilatory and cardiovascular support
  • Obtain focused history regarding timing of symptom onset
  • Collect information about medical history, medications (especially anticoagulants/antiplatelets)
  • Provide advance notice to ED to initiate critical pathways 1

• Emergency Department Management:

  • Immediate consultation with neurology, neurosurgery, and critical care
  • Parallel clinical evaluation by physicians and nurses
  • Monitor for early neurological deterioration (occurs in 15% of patients within first hour) 1

Diagnostic Imaging

• Neuroimaging is mandatory as clinical features alone cannot distinguish hemorrhage from ischemia 1
• CT scan is the gold standard for identifying acute hemorrhage
• MRI with gradient echo (GRE) and T2* susceptibility-weighted imaging is equally sensitive for acute blood and more sensitive for prior hemorrhage 1
• CT angiography may identify patients at high risk of hematoma expansion based on contrast extravasation 1

Medical Management

Blood Pressure Control

• Close monitoring of blood pressure is essential
• Avoid systemic hypotension in patients with cerebral hemorrhage 2
• Blood pressure lowering should be accomplished gradually, compatible with patient's clinical status 2
• For patients requiring BP reduction, nicardipine IV is an option:
  • Start at 5 mg/hr
  • Increase by 2.5 mg/hr every 5-15 minutes to maximum of 15 mg/hr until desired BP reduction is achieved
  • If hypotension occurs, discontinue infusion and restart at lower dose (3-5 mg/hr) 2

Management of Increased Intracranial Pressure

• For patients with signs of increased ICP:
  • Consider mannitol administration (with caution)
  • Monitor for renal complications, especially in patients with pre-existing renal disease 3
  • Watch for fluid and electrolyte imbalances, particularly sodium and potassium 3
  • Caution: Mannitol may increase cerebral blood flow and risk of postoperative bleeding in neurosurgical patients 3

Coagulopathy Management

• For patients on anticoagulants, reverse anticoagulation based on specific agent:
  • Warfarin: Prothrombin Complex Concentrate (PCC) with IV vitamin K
  • Heparin: Protamine 4
• Maintain fibrinogen levels >1.5 g/L and platelet count >75 × 10⁹/L 4
• Regular assessment of coagulation parameters every 30-60 minutes during active bleeding 4

Surgical Management

Indications for Surgical Intervention

• Surgical evacuation should be considered for:

  • Patients with progressive neurological deterioration
  • Large hematomas causing significant mass effect
  • Patients with focal neurological deficits 5, 6

• Conservative management is appropriate for:

  • Small hematomas (<1 cm in thickness)
  • Patients with minimal neurological dysfunction
  • Stable clinical course 7, 8, 6

Surgical Approach

• Craniotomy for hematoma evacuation has been shown to be a low-risk strategy with generally good outcomes 5
• Prompt surgical evacuation prior to neurological deterioration improves outcomes
• Patients who experience in-hospital neurological deterioration or coma before surgery have significantly worse outcomes 5

Monitoring and Follow-up

• Admit to critical care for close observation 4
• Regular assessment of:
  • Neurological status
  • Coagulation parameters
  • Hemoglobin levels
  • Blood gases 4
• Monitor for signs of rebleeding, which carries high mortality 4
• Serial CT scans to assess hematoma evolution 7

Prognosis

• Early intervention is crucial as early deterioration is common in the first few hours after onset 1
• Mortality rate can be high (up to 36%), with higher rates in patients managed non-operatively (50%) compared to surgical management (32%) 5
• Patients who undergo craniotomy before neurological deterioration have better outcomes 5
• Most motor deficits related to interhemispheric hemorrhage resolve with appropriate management 8

Special Considerations

• Patients on anticoagulants or antiplatelet medications (92% in one study) represent a high-risk group 5
• Interhemispheric subdural hematomas are more common than previously thought, representing 35.5% of all subdural hematomas in one study 8
• The classic presentation includes contralateral hemiparesis that is more pronounced in the lower extremity (falx syndrome) 6