What is the management plan for a patient with a brain bleed (cerebral hemorrhage)?

Management of Brain Hemorrhage (Intracerebral Hemorrhage)

Immediate CT imaging without contrast is mandatory to confirm the diagnosis and distinguish hemorrhage from ischemic stroke, followed by aggressive blood pressure control and reversal of any coagulopathy within the first hours to prevent hematoma expansion—the primary driver of early mortality. 1, 2

Initial Emergency Assessment and Stabilization

Airway and Breathing Management

• Secure the airway via tracheal intubation for any patient with Glasgow Coma Scale (GCS) ≤8 to prevent aspiration and ensure adequate oxygenation 3
• Maintain PaO₂ between 60-100 mmHg and PaCO₂ between 35-40 mmHg; avoid hyperventilation as it causes cerebral vasoconstriction and worsens brain ischemia 3

Hemodynamic Support

• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during initial resuscitation and any emergency interventions 1, 3
• This threshold prevents cerebral hypoperfusion while preparing for definitive blood pressure management

Immediate Diagnostic Imaging

• Obtain non-contrast CT scan immediately—this is the gold standard for identifying acute hemorrhage and determining hematoma volume 1, 2
• CT reveals hemorrhage location, volume, presence of hydrocephalus, and mass effect—all critical for treatment decisions 2

Blood Pressure Management

For patients with systolic BP >150 mmHg, aggressively lower blood pressure to prevent hematoma expansion, which occurs in over 20% of patients in the first few hours 2

• Hematoma expansion is the most modifiable predictor of neurologic deterioration and death 2, 4
• Active bleeding can continue for hours after symptom onset, making rapid BP control time-critical 2, 5
• The narrow therapeutic window demands immediate intervention upon diagnosis 4

Coagulopathy Reversal

For Patients on Anticoagulants

• Reverse anticoagulation as rapidly as possible for patients on warfarin or direct oral anticoagulants with life-threatening bleeding 2
• Anticoagulant-related intracerebral hemorrhage carries approximately 60% mortality, and bleeding often evolves slowly over 12-24 hours, making emergency reversal crucial 6

Platelet Management

• Administer platelets to maintain count >50×10⁹/L in patients with ongoing bleeding or those on antiplatelet agents 2

Surgical Decision-Making

Absolute Indications for Surgery

• Cerebellar hemorrhage with neurologic deterioration, brainstem compression, or hydrocephalus from ventricular obstruction requires immediate surgical evacuation 1, 2, 3
• This is one of the few Class I recommendations in ICH management 1

Relative Surgical Indications

• For most supratentorial ICH, surgery remains uncertain (Class IIb evidence) 2
• Lobar hemorrhages within 1 cm of the cortical surface may benefit from evacuation within 96 hours 2
• Consider surgery for putaminal or lobar hemorrhages when patients deteriorate despite maximal medical therapy 7
• Minimally invasive surgical techniques show promise and deserve consideration over conventional craniotomy, which has not demonstrated benefit 5

Intracranial Pressure Management

• Monitor ICP in patients with GCS ≤8, hydrocephalus, or clinical signs of transtentorial herniation 2
• Intensive medical therapy guided by continuous ICP monitoring may improve outcomes 7

Prevention of Secondary Complications

Venous Thromboembolism Prophylaxis

• Apply mechanical thromboprophylaxis (intermittent pneumatic compression and/or anti-embolic stockings) immediately 2, 3
• Initiate pharmacological thromboprophylaxis within 24 hours after bleeding has been controlled 2, 3

Medical Complications Monitoring

• Monitor for and aggressively manage pneumonia, cardiac events, acute kidney injury, fever, and seizures 2
• These complications significantly impact mortality and functional outcome 2

Prognostic Factors and Care Intensity

• Hematoma volume and admission GCS score are the most powerful predictors of 30-day mortality 2
• Avoid early pessimistic prognostication that leads to premature withdrawal of care—most patients present with small hemorrhages that are survivable with aggressive medical management 2, 3
• Most ICH deaths occur during initial hospitalization in the setting of withdrawn support, creating potential self-fulfilling prophecies 3

Critical Pitfalls to Avoid

• Do not delay intubation in patients with GCS ≤8—this is a clear indication for airway protection 3
• Never allow hypotension or hypoxia, as these worsen secondary brain injury and are associated with poor outcomes 3
• Do not rely on clinical examination alone to distinguish hemorrhage from ischemic stroke—neuroimaging is mandatory as clinical features overlap 3
• Do not use permissive hypotension strategies employed in other trauma settings—brain-injured patients require different blood pressure targets to prevent cerebral ischemia 1

Special Consideration: Traumatic Brain Injury with Hemorrhage

For polytrauma patients with TBI and hemorrhage, maintain hemoglobin >70 g/L using a restrictive transfusion strategy, as this threshold is associated with better neurologic outcomes and less progressive hemorrhagic injury compared to liberal transfusion (targeting 100 g/L) 1