What is the management approach for lamellar (intracerebral) hemorrhage in the brain?

Management of Lamellar Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) requires immediate neuroimaging with CT or MRI to confirm diagnosis, followed by aggressive management in a neurocritical care unit with specialized expertise to reduce mortality and improve outcomes. 1, 2

Initial Assessment and Stabilization

• Rapid neuroimaging: CT or MRI is mandatory to distinguish ICH from ischemic stroke (Class I, Level of Evidence A) 1

  • CT is the gold standard for identifying acute hemorrhage
  • Gradient echo and T2* susceptibility-weighted MRI are equally sensitive for acute blood and more sensitive for prior hemorrhage 1

• Baseline severity assessment: Perform a standardized severity score as part of initial evaluation (Class I, Level of Evidence B) 1

• Airway management: Secure airway if GCS ≤8 or deteriorating respiratory status 2

• Advanced imaging considerations:

  • CTA and contrast-enhanced CT may help identify patients at risk for hematoma expansion (Class IIb, Level of Evidence B) 1
  • Consider vascular imaging (CTA, CT venography, MRA, MRV) to evaluate for underlying structural lesions when clinically or radiologically suspected 1

Medical Management

Blood Pressure Control

• Intensive BP lowering: Target systolic BP <140 mmHg within 6 hours of ICH onset 2
  • Careful reduction (avoid decreases ≥60 mmHg within 1 hour)
  • Sustained management (minimize variability) during first 24 hours 3

Reversal of Coagulopathy

• For vitamin K antagonists (warfarin):

  • Administer prothrombin complex concentrate (PCC) and intravenous vitamin K (Class I, Level of Evidence C) 1, 2
  • PCC is preferred over fresh frozen plasma due to faster correction of INR 2

• For direct oral anticoagulants:

  • Dabigatran: Administer idarucizumab 2, 3
  • Factor Xa inhibitors: Administer andexanet alfa or PCC 2, 3

• For severe coagulation factor deficiency or thrombocytopenia:

  • Provide appropriate factor replacement therapy or platelets (Class I, Level of Evidence C) 1

Management of Intracranial Pressure

• For elevated ICP:
  • Mannitol: 0.25-2 g/kg body weight as a 15-25% solution administered over 30-60 minutes 4
  • Maintain head elevation at 30 degrees
  • Target cerebral perfusion pressure (CPP) between 50-70 mmHg in patients with ICP monitoring 2

Prevention of Complications

• DVT prophylaxis: Implement intermittent pneumatic compression beginning on admission day (Class I, Level of Evidence A) 1, 2

  • Avoid graduated compression stockings 2

• Fluid management: Maintain euvolemia rather than hypervolemia; avoid hypovolemia to prevent cerebral hypoperfusion 2

• Glucose management: Monitor glucose levels and avoid both hyperglycemia and hypoglycemia (Class I, Level of Evidence C) 2

• Seizure management: Prophylactic antiepileptic drugs confer no benefit 5

Surgical Management

Cerebellar Hemorrhage

• Surgical evacuation is strongly recommended for:
  • Cerebellar hemorrhages ≥3 cm in diameter
  • Patients with brainstem compression
  • Patients with hydrocephalus from ventricular obstruction (Class I, Level of Evidence B) 1, 2

Supratentorial Hemorrhage

• Consider surgical evacuation for:

  • Patients with neurological deterioration
  • Lobar clots within 1 cm of the cortical surface with GCS 9-12 1
  • Patients with large hematomas, significant midline shift, or elevated ICP refractory to medical management 2

• Minimally invasive surgery may be considered in select cases, though evidence is less robust than for conventional craniotomy 1

Intraventricular Hemorrhage (IVH)

• External ventricular drainage for hydrocephalus
• Intraventricular administration of rt-PA in IVH is considered investigational (Class IIb, Level of Evidence B) 1

Monitoring and Supportive Care

• Location of care: ICU or dedicated stroke unit with physician and nursing neuroscience acute care expertise (Class I, Level of Evidence B) 2

• Dysphagia screening: Perform formal screening before initiating oral intake (Class I, Level of Evidence B) 2

• Rehabilitation: All patients should have access to multidisciplinary rehabilitation (Class I, Level of Evidence A) 2

Prognostic Considerations

• Early neurological deterioration is common within the first few hours after ICH onset 1
• Hematoma expansion occurs in 28-38% of patients within 3 hours of onset and predicts poor outcomes 1
• One-year mortality varies by location: deep hemorrhages (51%), lobar (57%), cerebellar (42%), and brainstem (65%) 2
• Early prognostication is difficult; avoid early do-not-resuscitate orders or withdrawal of care within the first 24-48 hours 3

Common Pitfalls to Avoid

• Delayed neuroimaging: Time is brain - rapid diagnosis is essential to prevent hematoma expansion
• Inadequate coagulopathy reversal: Delays increase risk of hematoma expansion
• Overly aggressive BP reduction: Avoid decreases ≥60 mmHg within 1 hour to prevent cerebral hypoperfusion
• Early prognostication: Avoid premature withdrawal of care within first 24-48 hours
• Neglecting cerebellar hemorrhage: These require urgent surgical evaluation regardless of patient's neurological status