What are the symptoms and management of intracranial hemorrhage?

Intracranial Hemorrhage: Symptoms and Management

Intracranial hemorrhage is a medical emergency requiring rapid diagnosis and aggressive management to reduce the high morbidity and mortality associated with this condition. 1

Symptoms and Clinical Presentation

• Sudden onset of focal neurological deficits that often progress over minutes to hours 1
• Severe headache (more common in ICH than ischemic stroke) 1
• Vomiting (more common in ICH than either ischemic stroke or subarachnoid hemorrhage) 1
• Decreased level of consciousness or coma 1
• Elevated systolic blood pressure (often >220 mm Hg) 1
• Neurological deterioration (over 20% of patients experience a decrease in Glasgow Coma Scale of 2 or more points between prehospital assessment and emergency department evaluation) 1
• Progression of symptoms over minutes to hours (uncommon in ischemic stroke and rare in subarachnoid hemorrhage) 1

Emergency Diagnosis and Assessment

Immediate Actions

• Rapid neuroimaging with CT or MRI is mandatory to distinguish ICH from ischemic stroke 1
• CT is very sensitive for identifying acute hemorrhage and is considered the gold standard 1
• Gradient echo (GRE) and T2*susceptibility-weighted MRI are as sensitive as CT for detection of acute blood and more sensitive for identifying prior hemorrhage 1
• CT angiography (CTA) and contrast-enhanced CT may help identify patients at risk for hematoma expansion 1

Initial Management

• Ensure ventilatory and cardiovascular support 1
• Obtain focused history regarding timing of symptom onset and medical history 1
• Contact appropriate consultative services (neurology, neurosurgery, critical care) as quickly as possible 1
• Evaluate for underlying causes including hypertension, anticoagulant use, vascular malformations, tumors, and coagulopathies 1

Acute Management

Blood Pressure Control

• Elevated blood pressure is common and associated with hematoma expansion 1
• Aggressive blood pressure management is needed to prevent hematoma growth 1

Hemostasis and Coagulopathy Management

• For patients on oral anticoagulants with life-threatening bleeding, correct the international normalized ratio (INR) as rapidly as possible 1
• For patients with coagulation factor deficiency and thrombocytopenia, replacement of appropriate factor or platelets is indicated 1

Intracranial Pressure (ICP) Management

• ICP monitoring should be considered in patients with GCS ≤8, those with hydrocephalus, or those with clinical evidence of transtentorial herniation 1
• Elevated ICP may be more common in younger patients and those with supratentorial ICH 1
• Hydrocephalus from IVH or mass effect from the hematoma are common causes of elevated ICP 1

Surgical Management

• Immediate surgical evacuation is recommended for patients with cerebellar hemorrhage who are deteriorating neurologically, have brainstem compression, hydrocephalus, or cerebellar ICH volume ≥15 mL 2
• External ventricular drainage alone is potentially harmful and insufficient when there is brainstem compression 2
• Decompressive craniectomy may be considered for patients with high ICP and mass effect 2

Location-Specific Management

Brainstem Hemorrhage

• Immediate physiological stabilization, including airway management and ventilatory support 2
• A period of observation (24-72 hours) after initial stabilization to improve decision-making regarding prognosis 2
• Intubated patients require admission to critical care for observation 2

Cerebellar Hemorrhage

• Immediate surgical evacuation for patients who are deteriorating neurologically or have brainstem compression 2
• Surgery has been demonstrated to reduce mortality in cases of cerebellar hemorrhage 2

Prevention of Secondary Complications

• Monitor for and manage medical complications including pneumonia, cardiac events, and acute kidney injury 1
• Fever management is important as fever is associated with poor outcomes 1
• Seizure prophylaxis may be considered, especially in patients with lobar hemorrhages 1
• Deep venous thrombosis prophylaxis should be initiated once bleeding has stabilized 1

Prognosis and Rehabilitation

• Volume of ICH and Glasgow Coma Scale score on admission are the most powerful predictors of 30-day mortality 1
• Hydrocephalus is an independent indicator of 30-day death 1
• Cortical location, mild neurological dysfunction, and low fibrinogen levels have been associated with good outcomes in medium to large ICH 1
• Early aggressive care is warranted as most patients present with small ICHs that are readily survivable with good medical care 1