What is the management plan for a patient with a brain bleed?

Management of Brain Bleed

The management of brain bleed requires immediate intervention with a stepwise approach that prioritizes bleeding control, reversal of anticoagulation, blood pressure management, and surgical intervention when indicated to minimize morbidity and mortality. 1

Initial Assessment and Stabilization

• Immediate neuroimaging: Non-contrast head CT is essential to confirm ICH, assess hematoma size, location, and presence of intraventricular extension 1
• Neurological evaluation: Assess pupils and Glasgow Coma Scale motor score to determine severity of brain damage 2
• Airway management: Secure airway if GCS ≤8 or deteriorating neurological status 1
• Laboratory tests: Complete blood count, coagulation studies (PT/aPTT), and screening for underlying conditions 2, 1

Blood Pressure Management

• Target systolic BP: 140-160 mmHg within 1 hour of treatment initiation 1
• Avoid rapid decreases: Do not decrease BP >60 mmHg in the first hour as it may worsen outcomes 1
• First-line agents: Intravenous nicardipine or labetalol for smooth and titratable action 1
• Maintenance phase: Keep systolic BP 130-150 mmHg for 24-48 hours; avoid SBP <130 mmHg 1

Reversal of Anticoagulation

For patients on anticoagulants:

• Vitamin K antagonists (warfarin):

  • Immediately withhold medication
  • 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 2, 1

• Direct oral anticoagulants:

  • Dabigatran: Administer idarucizumab 2, 1
  • Factor Xa inhibitors (rivaroxaban, apixaban, edoxaban): Administer andexanet alfa 2, 1

ICP Management and Neurocritical Care

• ICP monitoring: Consider in patients with GCS ≤8, evidence of transtentorial herniation, or significant intraventricular hemorrhage 1
• Cerebral perfusion pressure: Maintain CPP ≥60 mmHg when ICP monitoring is available 2
• Stepwise approach for elevated ICP:
  1. Head elevation to 30 degrees
  2. Osmotherapy (mannitol or hypertonic saline)
  3. Hyperventilation (temporarily in cases of herniation)
  4. Consider surgical decompression for refractory cases 2, 1

Surgical Management

• Cerebellar hemorrhage: Surgical evacuation for hemorrhages >3 cm or those causing brainstem compression/hydrocephalus 1
• Ventricular drainage: For hydrocephalus, especially in patients with decreased level of consciousness 1
• Decompressive craniectomy: Consider for large hemispheric hemorrhages causing significant mass effect and midline shift 1
• Hematoma evacuation: Consider for lobar hemorrhages of intermediate size with progressive neurological deterioration 3

Prevention of Complications

• Thromboprophylaxis:

  • Apply intermittent pneumatic compression devices immediately 1
  • Consider pharmacological prophylaxis (LMWH or unfractionated heparin) 1-4 days after bleeding has stopped 1
  • Avoid inferior vena cava filters as routine thromboprophylaxis 1

• Seizure management:

  • Treat clinical seizures with antiseizure medications
  • Treat electrographic seizures found on EEG in patients with altered mental status 1

• Other supportive care:

  • Maintain normoglycemia
  • Use isotonic fluids (0.9% saline) for hydration
  • Avoid hypotonic solutions and synthetic colloids 1
  • Formal dysphagia screening before initiating oral intake 1

Special Considerations

• Simultaneous multisystem surgery: For patients requiring both intervention for life-threatening hemorrhage and emergency neurosurgery 2
• Cerebral venous thrombosis: Initiate anticoagulation (IV heparin or SC LMWH) if no major contraindications, even in the presence of hemorrhagic conversion 2

Pitfalls to Avoid

• Delaying reversal of anticoagulation while waiting for laboratory results 2
• Using corticosteroids for treatment of elevated ICP in ICH 1
• Administering tPA for new ischemic events in patients with recent ICH 1
• Routine transfusion of platelets in patients taking aspirin or clopidogrel without evidence of benefit 4
• Neglecting to monitor for and treat hydrocephalus, which can develop precipitously 5

By following this structured approach to brain bleed management, focusing on early intervention, blood pressure control, and appropriate surgical management when indicated, patient outcomes can be significantly improved.