What is the treatment for a brain bleed?

Treatment of Brain Bleed

The treatment of brain bleed (intracerebral hemorrhage) requires aggressive early management including rapid diagnosis, blood pressure control, reversal of coagulopathy, and in select cases, surgical intervention to improve survival and functional outcomes. 1, 2

Initial Assessment and Management

• Rapid neuroimaging with CT or MRI is mandatory to distinguish intracerebral hemorrhage from ischemic stroke, with CT being the gold standard for identifying acute hemorrhage 1, 2
• Early deterioration is common in the first few hours after onset, with over 20% of patients experiencing a decrease in Glasgow Coma Scale (GCS) of two or more points between prehospital assessment and emergency department evaluation 1
• Primary objectives in prehospital setting include providing ventilatory and cardiovascular support and transporting the patient to the closest facility prepared to care for acute stroke patients 1

Blood Pressure Management

• Aggressive blood pressure management is recommended to prevent hematoma growth in patients with intracerebral hemorrhage 2
• The high rate of early neurologic deterioration is partly related to active bleeding that may proceed for hours after symptom onset 1
• Hematoma expansion is predictive of clinical deterioration and increased morbidity and mortality 1

Coagulopathy Management

• For patients on oral anticoagulants with life-threatening bleeding, correction of international normalized ratio (INR) should be done as rapidly as possible 2
• Platelets should be administered to maintain a platelet count above 50×10^9/l in patients with ongoing bleeding and/or traumatic brain injury 1
• Mechanical thromboprophylaxis with intermittent pneumatic compression and/or anti-embolic stockings may be applied as soon as possible, with pharmacological thromboprophylaxis employed within 24 hours after bleeding has been controlled 1

Surgical Management

• For most patients with ICH, the usefulness of surgery is uncertain (Class IIb, Level of Evidence C) 1
• Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brain stem compression and/or hydrocephalus from ventricular obstruction should undergo surgical evacuation 1, 2
• The STICH trial found that patients with hematomas extending to within 1 cm of the cortical surface had a trend towards more favorable outcome with surgery within 96 hours 1
• Patients with lobar hemorrhages and a GCS of 9-12 also showed a trend towards better outcome with surgical intervention 1

Intraventricular Hemorrhage Management

• Extension of hemorrhage into the ventricles (occurs in approximately 40% of cases) is directly related to the degree of injury and likelihood of survival 3
• The most immediate threat to life posed by intraventricular hemorrhage is the development of acute obstructive hydrocephalus, which may require emergency treatment with external ventricular drainage 4
• Intraventricular injections of thrombolytic agents through an intraventricular catheter may be considered in patients with intraventricular hemorrhage causing or threatening to cause obstructive hydrocephalus 4

Prevention of Secondary Complications

• Monitoring for and managing medical complications, including pneumonia, cardiac events, and acute kidney injury, as well as fever management and seizure prophylaxis is recommended 2
• Deep venous thrombosis prophylaxis should be initiated once bleeding has stabilized 2
• Intracranial pressure (ICP) monitoring should be considered in patients with GCS ≤8, those with hydrocephalus, or those with clinical evidence of transtentorial herniation 2

Prognosis Factors

• The volume of intracerebral hemorrhage and Glasgow Coma Scale score on admission are the most powerful predictors of 30-day mortality 2
• Early aggressive care is warranted as most patients present with small intracerebral hemorrhages that are readily survivable with good medical care 1, 2
• Time-dependent factors such as time from symptom onset and time to treatment are critical predictors of outcomes in anticoagulant-related intracerebral bleeds 5