What is the initial management of intracranial hemorrhage?

Initial Management of Intracranial Hemorrhage

The initial management of intracranial hemorrhage should focus on securing the airway, stabilizing blood pressure, reversing anticoagulation if present, and rapid neuroimaging to determine the type, location, and extent of hemorrhage to guide further treatment decisions. 1, 2

Immediate Stabilization

Airway Management

• Secure airway if GCS ≤8 or deteriorating respiratory status 1
• Indications for immediate intubation:
  • Glasgow Coma Scale (GCS) score ≤8
  • Deteriorating consciousness
  • Loss of protective laryngeal reflexes
  • Respiratory insufficiency
  • Spontaneous hyperventilation
  • Seizures

Blood Pressure Management

• Target systolic BP 100-160 mmHg 1
• Maintain cerebral perfusion pressure (CPP) between 50-70 mmHg in patients with ICP monitoring 1
• Avoid hypotension as it adversely affects neurological outcome 1

Fluid Management

• Maintain euvolemia rather than hypervolemia 1
• Consider judicious use of vasopressors to offset hypotension 1

Reversal of Anticoagulation

For Vitamin K Antagonists (e.g., Warfarin)

• Immediately discontinue when ICH is present or suspected 2
• Administer vitamin K in combination with reversal agents 1
• Prothrombin complex concentrate is preferred over fresh frozen plasma 1

For Low Molecular Weight Heparin (LMWH)

• Discontinue LMWH when ICH is present or suspected 2
• Administer protamine by slow IV injection over 10 minutes according to the following dosing 2:
  • For enoxaparin within 8 hours: 1 mg protamine per 1 mg enoxaparin (maximum 50 mg)
  • For enoxaparin within 8-12 hours: 0.5 mg protamine per 1 mg enoxaparin
  • For dalteparin, nadroparin, and tinzaparin: 1 mg protamine per 100 anti-Xa units of LMWH

For Thrombolytic Agents

• Discontinue thrombolytic agents when ICH is present or suspected 2
• Consider cryoprecipitate (10 units initial dose) for symptomatic ICH related to thrombolytic agents used within previous 24 hours 2
• Check fibrinogen levels after administration of reversal agents; if <150 mg/dL, administer additional cryoprecipitate 2

For Antiplatelet Agents

• Discontinue antiplatelet agents when ICH is present or suspected 2
• Platelet transfusion is not recommended for patients with antiplatelet-associated ICH who will not undergo neurosurgical procedures 2
• Consider platelet transfusion for patients with aspirin or ADP inhibitor-associated ICH who will undergo neurosurgical procedures 2

Neuroimaging

• Immediate CT scan is essential for all suspected ICH cases 2, 3
• For patients on anticoagulants, the threshold for initial imaging is very low due to higher risk of ICH 2
• CT scan helps identify:
  • Type of hemorrhage (intraparenchymal, subarachnoid, subdural, epidural)
  • Location and volume of hemorrhage
  • Presence of intraventricular extension
  • Midline shift or hydrocephalus
  • Underlying structural abnormalities 3

Surgical Management Considerations

For Cerebellar ICH

• Immediate surgical removal of the hemorrhage with or without EVD is recommended for patients who are deteriorating neurologically, have brainstem compression and/or hydrocephalus from ventricular obstruction, or have cerebellar ICH volume ≥15 mL 2

For Supratentorial ICH

• Consider craniotomy for hematoma evacuation as a life-saving measure in patients who are deteriorating 2
• Surgical evacuation is indicated for significant acute subdural hematomas with thickness >5 mm and midline shift >5 mm, regardless of GCS score 1

Prevention of Complications

• Initiate intermittent pneumatic compression for prevention of venous thromboembolism beginning on day of admission 1
• Avoid graduated compression stockings for DVT prophylaxis 1
• Monitor for and treat fever, although therapeutic cooling has not been shown to improve outcomes 4
• Formal screening for dysphagia before initiating oral intake 1
• Monitor glucose and avoid both hyperglycemia and hypoglycemia 1

Post-Acute Care

• Initial monitoring and management should take place in an ICU or dedicated stroke unit with neuroscience expertise 1
• All patients should have access to multidisciplinary rehabilitation 1

Prognostic Factors

Poor prognostic factors include:

• Larger hematoma volume
• Lower initial GCS score
• Presence of intraventricular hemorrhage
• Age >60 years
• Location (brainstem hemorrhages have worst prognosis at 65% 1-year mortality) 1

The initial management of ICH is critical as early deterioration is common in the first few hours after onset. A systematic approach focusing on airway protection, blood pressure control, reversal of coagulopathy, and timely surgical intervention when indicated can significantly impact patient outcomes.