What is the management of a cranial bleed after a head injury?

Management of Cranial Bleed After Head Injury

The management of cranial bleeding after head injury requires immediate assessment, stabilization, and targeted interventions to minimize secondary brain injury and improve mortality and neurological outcomes.

Initial Assessment and Resuscitation

Primary Survey

• Ensure airway patency, adequate breathing, and circulatory stability
• Perform rapid neurological assessment (GCS motor score + pupils) 1
• Maintain systolic blood pressure >110 mmHg (MAP >80 mmHg) to ensure adequate cerebral perfusion 2
• Avoid hypotension (SBP <100 mmHg) as it is associated with worse neurological outcomes 1
• Avoid hypotonic solutions (such as Ringer's lactate) in patients with severe head trauma 1

Diagnostic Imaging

• Immediate CT scan of the head to identify type, location, and extent of intracranial bleeding 1
• Early focused sonography (FAST) should be employed for detection of free fluid in patients with suspected torso trauma 1
• Haemodynamically stable patients with suspected head, chest and/or abdominal bleeding following high-energy injuries should undergo further assessment using CT 1

Blood Pressure Management

Target Blood Pressure

• For isolated traumatic brain injury:
  • Maintain SBP >110 mmHg (and MAP >90 mmHg) but <150 mmHg 2
  • Target cerebral perfusion pressure (CPP) between 60-70 mmHg 2
• For TBI with polytrauma and active bleeding:
  • Maintain SBP >100 mmHg during hemorrhage control 1
  • Avoid prolonged hypotension as it significantly worsens outcomes 1

Fluid Resuscitation

• Use 0.9% saline for initial fluid resuscitation 2
• Avoid hypotonic solutions in patients with traumatic brain injury 1
• If hypotension persists after volume correction, initiate norepinephrine infusion 2

Surgical Management

Indications for Immediate Surgical Intervention

• Minimize time between injury and operation for patients needing urgent surgical bleeding control 1
• Patients with significant intracranial hematoma and hemodynamic instability should undergo urgent surgery 1
• Damage control surgery should be employed in severely injured patients with deep hemorrhagic shock, signs of ongoing bleeding and coagulopathy 1

Surgical Approaches

• Craniotomy for evacuation of large epidural, subdural, or intraparenchymal hematomas causing significant mass effect
• Decompressive craniectomy may be considered for diffuse cerebral edema with refractory intracranial hypertension
• Ventricular drainage for hydrocephalus in patients with decreased level of consciousness 2

Management of Intracranial Pressure (ICP)

ICP Monitoring

• Consider ICP monitoring in severe TBI patients, particularly after evacuation of intracranial hematomas 2
• Indications include: GCS motor response ≤5, preoperative anisocoria or bilateral mydriasis, preoperative hemodynamic instability, or severe findings on cerebral imaging 2

ICP Management

• Maintain ICP <20-25 mmHg
• For elevated ICP, consider:
  • Mannitol 0.25-2 g/kg IV administered over 30-60 minutes 3
  • Avoid mannitol in patients with severe dehydration, severe pulmonary congestion, or active intracranial bleeding except during craniotomy 3
  • Monitor for side effects of osmotic agents, including mannitol-induced osmotic diuresis 2
  • Ensure normoventilation; avoid hyperventilation unless there are signs of imminent cerebral herniation 1

Coagulation Management

Blood Product Administration

• Maintain hemoglobin >7 g/dL 1, 2
• Maintain platelet count >50×10^9/L in patients with ongoing bleeding and/or traumatic brain injury 1
• Correct coagulopathy to maintain PT/aPTT <1.5 times normal control 2
• Consider antifibrinolytic agents (tranexamic acid) in bleeding trauma patients 1

Anticoagulation/Antiplatelet Reversal

• For patients on anticoagulants or antiplatelet medications, rapid reversal is essential
• Patients on antiplatelet medications have a 4.3% risk of traumatic intracranial hemorrhage after ground-level falls 4

Monitoring and Follow-up

Neurological Monitoring

• Regular neurological assessments to detect deterioration
• Patients with a normal neurological examination have a high negative predictive value (100% in one study) for progression requiring neurosurgical intervention 5
• Monitor for signs of increased ICP: decreasing GCS, pupillary changes, Cushing's triad

Repeat Imaging

• Consider repeat CT scan if neurological deterioration occurs
• Routine repeat CT scan may not be necessary in patients with minimal head injury and normal neurological examination 5

Special Considerations

Polytrauma Management

• In patients with both TBI and extra-cranial bleeding, prioritize bleeding control while minimizing secondary brain injury 1
• Simultaneous multisystem surgery may be required for uncontrolled hemorrhage in TBI polytrauma patients 1
• Damage control surgery should be employed in severely injured patients with deep hemorrhagic shock, signs of ongoing bleeding and coagulopathy 1

Temperature Management

• Maintain normothermia in patients with traumatic brain injury 1
• Consider targeted temperature management (33-35°C for 48h) in patients with traumatic brain injury once bleeding from other sources has been controlled 1

Prognosis

• Large intracranial bleeds (epidural, subdural, intraparenchymal) are associated with substantially higher probability of hospital mortality compared to small bleeds 6
• Factors associated with poor outcome include older age, higher injury severity score, and presence of intracranial hematoma 7