What is the treatment for brain hemorrhage?

Treatment of Brain Hemorrhage (Intracerebral Hemorrhage)

Brain hemorrhage requires immediate aggressive medical management focused on preventing hematoma expansion, controlling blood pressure, reversing coagulopathy, managing intracranial pressure, and providing specialized neurocritical care—with surgical intervention reserved for specific indications such as cerebellar hemorrhage >3 cm or deteriorating patients with superficial lobar hemorrhages. 1, 2

Immediate Emergency Management

Prehospital and Emergency Department Priorities

• Transport immediately to a stroke-capable facility with neurology, neurosurgery, neuroradiology, and critical care capabilities available 1, 3
• Provide ventilatory and cardiovascular support during transport 1
• Obtain emergent CT scan to confirm diagnosis—clinical features alone cannot distinguish hemorrhagic from ischemic stroke 1, 3
• Activate critical pathways immediately upon arrival, as 15% of patients deteriorate (GCS decrease ≥2 points) within the first hour of hospital presentation 1

Blood Pressure Management

For patients presenting within 6 hours with systolic BP >150 mmHg, aggressively reduce blood pressure to <140-160 mmHg if immediate surgery is not planned 2, 3. This prevents hematoma expansion, which occurs in 28-38% of patients scanned within 3 hours and directly predicts mortality 1.

• Target systolic BP <160 mmHg for unsecured aneurysms 4
• Avoid hypotension (systolic <110 mmHg) as this worsens secondary brain injury 4, 3
• Use small boluses of labetalol with increased sedation for hypertension control 4

Reversal of Coagulopathy

Immediately reverse anticoagulation in all anticoagulated patients with ICH 2, 3:

• Warfarin (vitamin K antagonists): Administer four-factor prothrombin complex concentrate (PCC) plus vitamin K 2, 3
• Dabigatran: Administer idarucizumab; if unavailable, consider hemodialysis 3
• Factor Xa inhibitors (rivaroxaban, apixaban): Administer four-factor PCC (50 U/kg) or activated PCC (50 U/kg) 3
• Heparin: Administer protamine sulfate at 1 mg per 100 units of heparin given in previous 2-3 hours (maximum 50 mg single dose) 3

Use prothrombin complex concentrate rather than fresh frozen plasma to limit fluid volumes 4

Intracranial Pressure Management

ICP Monitoring and Treatment

• Consider ICP monitoring for patients with GCS ≤8, hydrocephalus, or clinical evidence of transtentorial herniation 2, 3
• Elevate head of bed to 30 degrees for patients with elevated ICP 3
• Use osmotic agents (mannitol and hypertonic saline) to produce hyperosmolality and euvolemia in patients with elevated ICP 2, 5
• CSF drainage via external ventricular drainage is recommended for hydrocephalus or ventricular obstruction 2

Contraindicated Interventions

• Do NOT use corticosteroids (steroids) in ICH management—they are specifically contraindicated 2
• Do NOT use acetazolamide in ICH management 2
• Avoid medications causing cerebral vasodilation or increased cerebral blood volume as these worsen intracranial compliance and can precipitate herniation 2

Fluid Management

• Use 0.9% saline as the crystalloid of choice—it is isotonic and prevents worsening cerebral edema 2, 4
• Avoid hypotonic solutions (Ringer's lactate, Ringer's acetate, gelatins) as they increase brain water content 4
• Avoid albumin or synthetic colloids in early management 4

Surgical Management

Cerebellar Hemorrhage

Patients with cerebellar hemorrhage >3 cm diameter, or any size with brainstem compression or hydrocephalus, require surgical decompression 1, 3. This is the strongest surgical indication, as deterioration occurs rapidly in the narrow posterior fossa 1.

• Ventriculostomy alone is insufficient and potentially harmful—hematoma evacuation is required 1
• Brainstem hemorrhages should generally NOT be evacuated as this may be harmful 1

Supratentorial Hemorrhage

The benefit of routine surgical evacuation for supratentorial ICH remains uncertain 1:

• Consider surgery for superficial lobar hemorrhages within 1 cm of cortical surface in conscious patients without intraventricular hemorrhage, particularly if deteriorating 1
• The STICH II trial showed no significant benefit for early surgery in lobar hemorrhage overall, though a non-prespecified subgroup with poor prognosis may benefit 1
• Decompressive craniectomy may be considered for patients with GCS <8, significant midline shift, or refractory elevated ICP, though evidence is limited 1

Prevention of Secondary Complications

Venous Thromboembolism Prophylaxis

• Initiate mechanical thromboprophylaxis with intermittent pneumatic compression devices immediately 4, 3
• Consider pharmacological thromboprophylaxis within 24-48 hours after confirming hemorrhage stability on repeat imaging 4, 3

Specialized Care Setting

• Transfer to specialized neuroscience or stroke unit when stabilized 4, 3
• Specialized nursing care with stroke competencies reduces mortality 4
• Implement evidence-based treatment algorithms and checklists 4

Monitoring and Supportive Care

• Perform frequent neurological assessments including GCS in the early phase to detect deterioration 4
• Monitor for and manage medical complications including pneumonia, cardiac events, and acute kidney injury 4, 3
• Maintain platelet count >50×10^9/L in patients with ongoing bleeding 4
• Ensure adequate ventilatory support with initial normoventilation unless imminent herniation 4

Critical Pitfalls to Avoid

• Do NOT delay anticoagulation reversal—this is time-critical 4
• Do NOT transfer hypotensive, actively bleeding patients—control bleeding first 4
• Do NOT use hypotonic fluids which worsen cerebral edema 4
• Do NOT administer nimodipine intravenously—this drug is only for subarachnoid hemorrhage and oral/enteral administration only 6
• Do NOT use routine platelet transfusion for patients on aspirin or clopidogrel without evidence of benefit 7
• Do NOT use recombinant factor VIIa routinely—it reduces hematoma expansion but does not improve outcome and increases thromboembolic complications 7

Prognostic Factors

• Hematoma volume and admission GCS score are the most powerful predictors of 30-day mortality 3
• Most patients present with small ICHs that are readily survivable with excellent medical care 1
• Early aggressive care significantly impacts outcome 1, 8