What is the treatment for intraparenchymal hemorrhage?

Treatment for Intraparenchymal Hemorrhage

The treatment of intraparenchymal hemorrhage centers on aggressive medical stabilization with intensive blood pressure reduction to <140 mmHg systolic within 6 hours, avoidance of routine surgical evacuation for supratentorial hemorrhages, and selective surgical intervention only for cerebellar hemorrhages >3 cm with neurological deterioration or posterior fossa compression. 1

Immediate Medical Management

Airway, Breathing, and Circulation Stabilization

• Optimize respiratory effort and secure the airway in patients with Glasgow Coma Scale (GCS) ≤8 2, 1
• Initiate intensive care monitoring focused on core physiological parameters 3, 4

Blood Pressure Control

• Reduce systolic blood pressure to <140 mmHg within the first 6 hours of hemorrhage onset 1
• This intensive BP reduction strategy is critical for preventing hematoma expansion, which occurs in >20% of patients in the first hours 1
• Control systemic hypertension to prevent further bleeding while maintaining adequate cerebral perfusion 2

Intracranial Pressure Management

• Place external ventricular drain (EVD) for hydrocephalus in patients with decreased level of consciousness 1
• Consider ICP monitoring for patients with GCS ≤8, clinical evidence of transtentorial herniation, or significant intraventricular hemorrhage 1
• Maintain cerebral perfusion pressure between 50-70 mmHg based on autoregulation status 1
• Use osmotic agents (mannitol, glycerol) for elevated ICP 5
• Do NOT administer corticosteroids for elevated ICP in intraparenchymal hemorrhage 1

Seizure Prevention

• Prevent epileptic seizures, though prophylactic antiepileptic drugs show no proven benefit 2, 4

Hemostatic Considerations

• Avoid hemostatic therapy for acute hemorrhage not associated with antithrombotic drug use 1
• Correct known coagulopathies when present 2, 4
• Reverse oral anticoagulation if applicable 4
• Do NOT routinely transfuse platelets in patients taking aspirin or clopidogrel 4
• Recombinant factor VIIa reduces hematoma expansion but does not improve outcomes and increases thromboembolic complications 4

Surgical Management

Supratentorial Hemorrhage

There is no compelling evidence that surgical evacuation of supratentorial intraparenchymal hematoma is beneficial at any age. 2 A randomized trial of 1,033 adults found no benefit from early (<24 hours) hematoma evacuation, and a smaller study was halted after rebleeding occurred in 4 of 11 patients who had early (<4 hours) evacuation 2.

• Surgery may be considered for selected lobar hemorrhages, though benefits are not clearly established 1
• Anecdotal evidence suggests evacuation may alleviate impending brain herniation in selected individuals with large cerebral hemisphere lesions 2
• Early surgery is recommended for patients with GCS 9-12 1

Cerebellar Hemorrhage

Patients with cerebellar hemorrhage >3 cm who deteriorate neurologically or have brainstem compression and/or hydrocephalus from ventricular obstruction must undergo surgical removal of the hemorrhage as soon as possible. 1 This is the clearest indication for surgical intervention, as cerebellar hemorrhages carry unique risks of posterior fossa compression 2.

Minimally Invasive Techniques

• Endoscopic aspiration with continuous neuroendoscopic lavage has shown mortality reduction (42% vs 70% medical management) in small trials, particularly for lobar hematomas in patients ≤60 years 2
• Stereotactic urokinase infusion (5,000 IU every 6 hours for maximum 48 hours) achieved 40% median hematoma reduction but carried 35% rebleeding rate 2
• Intraventricular tPA for severe intraventricular hemorrhage decreased mortality from 60-90% to 5% compared to ventriculostomy alone 2

Prevention of Complications

Venous Thromboembolism Prophylaxis

• Initiate pharmacological VTE prophylaxis after documenting hemorrhage stability on CT, typically between 24-48 hours after onset 1, 6
• Use intermittent pneumatic compression for immobile patients immediately 1
• Avoid graduated compression stockings 1

Vasospasm Management (for Subarachnoid Extension)

• Maintain euvolemia rather than hypervolemia 2
• Avoid prophylactic hyperdynamic therapy 2
• Treat symptomatic vasospasm with induced hypertension after aneurysm treatment 2

Diagnostic Evaluation for Underlying Causes

Vascular Imaging

• Perform 4-vessel catheter angiography for unexplained hemorrhage to identify treatable vascular anomalies (AVMs, aneurysms, cavernous malformations) 2
• Complete noninvasive evaluation first, avoiding angiography when there is obvious explanation 2
• The rebleeding risk from untreated cavernous malformations is 4.5% per year 2

Hematologic Evaluation

• Thoroughly evaluate for hematologic disorders and coagulation defects 2
• Brain hemorrhage is rare with platelet counts >20,000/mm³ 2
• Administer factor VII for severe factor VII deficiency to prevent traumatic hemorrhage 2

Rehabilitation and Follow-up

• All patients must have access to multidisciplinary rehabilitation 1
• Initiate rehabilitation as early as possible and continue in the community 1
• Coordinate well-organized discharge planning with accelerated home reintegration 1

Critical Pitfalls to Avoid

• Do NOT perform routine early surgical evacuation of supratentorial hemorrhages—this increases rebleeding risk without improving outcomes 2
• Do NOT use corticosteroids for ICP management in intraparenchymal hemorrhage 1
• Do NOT delay cerebellar hemorrhage evacuation when indicated—this is the one clear surgical emergency 1
• Do NOT start VTE prophylaxis before 24 hours without documented hemorrhage stability 1, 6
• Large hematoma volume (>30 mL) independently predicts expansion and requires closer monitoring 6