What is the management and aftercare for a brain hemorrhage?

Management and Aftercare for Brain Hemorrhage

The management of brain hemorrhage requires immediate intervention with aggressive early care, including rapid diagnosis, hemodynamic stabilization, and consideration of surgical intervention when appropriate, as early deterioration is common and can significantly impact outcomes. 1

Initial Management

Prehospital and Emergency Department Care

• Provide ventilatory and cardiovascular support while transporting the patient to the closest facility prepared to care for acute stroke patients 1
• Obtain focused history regarding symptom onset timing and medical history, including medications and drug use 1
• Provide advance notice to the emergency department to initiate critical pathways and alert consulting services 1
• Perform urgent neurological evaluation including pupillary assessment and Glasgow Coma Scale (GCS) motor score 2
• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during initial interventions 1

Immediate Diagnostic Evaluation

• Perform urgent brain CT scan to identify potential intracranial injuries and determine if there are life-threatening lesions requiring neurosurgical intervention 2
• CT is very sensitive for identifying acute hemorrhage and is considered the gold standard; gradient echo (GRE) and T2*susceptibility-weighted MRI are equally sensitive for detection of acute blood and more sensitive for identification of prior hemorrhage 1
• Assess for signs of intracranial hypertension on CT scan 2

Medical Management

Airway and Ventilation Management

• Secure airway via tracheal intubation for patients with GCS score of 8 or less 3
• Maintain arterial partial pressure of oxygen (PaO₂) between 60-100 mmHg 2
• Maintain arterial partial pressure of carbon dioxide (PaCO₂) between 35-40 mmHg to prevent cerebral vasoconstriction and risk of brain ischemia 2

Blood Pressure Management

• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during interventions for life-threatening hemorrhage or emergency neurosurgery 1
• When ICP monitoring becomes available, maintain cerebral perfusion pressure (CPP) ≥60 mmHg, adjusted based on neuromonitoring data and cerebral autoregulation status 2

Coagulation Management

• Maintain platelet count above 50×10⁹/l in patients with ongoing bleeding and/or traumatic brain injury 1
• Maintain prothrombin time (PT)/activated partial thromboplastin time (aPTT) <1.5 normal control during interventions 2
• Consider point-of-care tests (thromboelastography/ROTEM) to assess and optimize coagulation function 2
• For patients requiring massive transfusion, use RBCs/plasma/platelets at a ratio of 1:1:1 initially, then modify according to laboratory values 2

Intracranial Pressure Management

• For patients at risk for intracranial hypertension, implement ICP monitoring regardless of the need for emergency extra-cranial surgery 2
• In cases of cerebral herniation, use osmotherapy (mannitol or hypertonic saline) and/or temporary hypocapnia 2
• Position patient with 20-30° head-up tilt to reduce intracranial pressure 3
• Use a stepwise approach for elevated ICP, reserving more aggressive interventions with greater risks for situations when no response is observed 2

Surgical Management

Indications for Surgery

• All salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation and intervention 2
• For most patients with intracerebral hemorrhage (ICH), the usefulness of surgery is uncertain 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

Timing of Surgery

• The optimal timing for surgical intervention remains controversial, with studies reporting wide variability in timing from within 4 hours up to 96 hours from symptom onset 1
• Early surgery (within hours of onset) may increase risk of rebleeding in some cases 1
• Minimally invasive clot removal techniques using stereotactic guidance combined with thrombolytic-enhanced or endoscopic-enhanced aspiration within 12-72 hours have shown decreased mortality but not consistently improved functional outcomes 1

Aftercare and Rehabilitation

Prevention of Complications

• Implement mechanical thromboprophylaxis with intermittent pneumatic compression and/or anti-embolic stockings as soon as possible 1
• Employ pharmacological thromboprophylaxis within 24 hours after bleeding has been controlled 1
• Maintain normothermia through early application of measures to reduce heat loss and warm hypothermic patients 1
• Monitor for and aggressively treat infections, fever, and acute lung injury, as these are strong drivers of increased length of stay 4

Outcome Prediction and Care Limitations

• Recognize that most patients who die from ICH do so during initial hospitalization, often in the setting of withdrawal of support due to presumed poor prognosis 1
• Be aware that early care limitations such as DNR orders within the first day of hospitalization are independent outcome predictors that may bias outcome prediction models 1
• Avoid early pessimistic prognostication that may lead to self-fulfilling prophecies of poor outcome by limiting aggressive care in severely ill ICH patients who still have possibilities of favorable outcome 1

Common Pitfalls to Avoid

• Do not delay intubation in patients with low GCS scores, as this is a clear indication for airway protection 3
• Avoid hypotension and hypoxia, which can worsen secondary brain injury 3
• Do not rely solely on clinical characteristics to determine whether symptoms are due to ischemia or hemorrhage, as neuroimaging is mandatory 1
• Recognize that the overall aggressiveness of ICH care at a hospital may be critically important in determining patients' outcomes, irrespective of specific individual interventions 1