What is the treatment for an acute parenchymal bleed of 18cc?

Treatment of Acute Parenchymal Bleed (18cc)

For an 18cc acute parenchymal brain hemorrhage, immediate medical management with aggressive blood pressure control to a systolic target of 140 mmHg, correction of any coagulopathy, and close neurological monitoring in an ICU setting is the primary treatment approach, with surgical intervention reserved for patients with deteriorating neurological status or signs of herniation. 1, 2

Immediate Assessment and Stabilization

Blood Pressure Management

• Target systolic blood pressure of 140 mmHg should be achieved rapidly using intravenous beta-blockers or calcium channel blockers for small to moderate hemorrhages (18cc qualifies as moderate) without signs of intracranial hypertension 2
• Avoid permissive hypotension strategies used in trauma (80-100 mmHg target) as these apply to extracranial bleeding, not intracerebral hemorrhage 1
• Rapid blood pressure lowering has been demonstrated to be safe and at least partially effective in preventing hematoma expansion 2

Coagulopathy Reversal

• Immediately reverse any anticoagulation or antiplatelet therapy - check INR, aPTT, platelet count, and anticoagulant history 1, 2
• For warfarin: administer prothrombin complex concentrates (PCC) for rapid reversal 1
• Avoid platelet transfusion in patients on antiplatelet medications as recent trials demonstrate no benefit and potential harm 2
• Correct coagulopathy as soon as possible even though hemostatic therapy has not been definitively shown to reduce hematoma expansion 2

Hemostatic Therapy

• Tranexamic acid should be administered as 1g IV over 10 minutes, followed by 1g IV over 8 hours, ideally within 3 hours of symptom onset 1, 3
• Do not wait for viscoelastic assessment results before administering TXA 3
• Early administration within the first hour shows greatest benefit for traumatic brain injury, though evidence for spontaneous ICH is less robust 3

Neurological Monitoring and ICU Care

Initial Monitoring Requirements

• Disposition to a dedicated neurological ICU is essential for patients with parenchymal hemorrhage 2
• Perform baseline and serial NIHSS scores at defined intervals (immediately, 24 hours, 72 hours, 7-10 days) 1
• Obtain non-contrast CT at 24 hours to assess for hematoma expansion, then at 7-10 days, 30 days, and 90 days 1
• Monitor continuously for signs of neurological deterioration requiring emergency imaging 1

ICP Monitoring Indications

• Consider ICP monitoring for patients with GCS ≤8, clinical evidence of transtentorial herniation, or significant mass effect 1
• Maintain cerebral perfusion pressure (CPP) of 50-70 mmHg depending on autoregulation status 1
• Ventricular drainage is reasonable for hydrocephalus treatment, especially in patients with decreased level of consciousness 1
• Use ventriculostomy catheter rather than parenchymal device if CSF drainage is needed for hydrocephalus or elevated ICP 1

Surgical Decision-Making

Indications for Surgical Intervention

• Surgery should be considered for patients with deteriorating neurological status despite medical management 2
• Select patients with intraventricular extension may benefit from stereotactically guided catheter drainage 2
• An 18cc hemorrhage typically does not require immediate surgical evacuation unless there is significant mass effect, midline shift, or clinical deterioration 1, 2
• Damage control neurosurgery principles apply if patient demonstrates hemorrhagic shock, coagulopathy, hypothermia, or acidosis 4

Surgical Timing Considerations

• Minimize time between identification of need for intervention and definitive control 4
• Emergency surgical consultation is necessary for signs of herniation or rapid neurological decline 1
• Stereotactically guided drainage with intraventricular hemorrhage has been shown to be safe and improve outcomes 2

Ongoing Medical Management

Temperature and Metabolic Control

• Employ early measures to reduce heat loss and maintain normothermia 1
• Avoid hyperventilation in severely hypovolemic patients 1
• Monitor serum lactate and base deficit to estimate extent of shock if present 1

Seizure Prophylaxis

• Monitor for seizures throughout hospitalization 2
• Obtain additional NIHSS score if seizures occur to assess neurological impact 1

Hemoglobin Management

• Target hemoglobin of 70-90 g/L if transfusion is necessary 1
• Patients with severe traumatic brain injury should not be managed with different Hb thresholds than other critically ill patients 1
• Increasing Hct above 28% during initial phase following severe brain injury is not associated with improved outcome 1

Critical Pitfalls to Avoid

• Never use corticosteroids for intracerebral hemorrhage - they are contraindicated 1
• Avoid cyclosporine-A in patients with nervous system involvement, even if no longer active 1
• Do not delay correction of coagulopathy while awaiting laboratory results 1, 2
• Avoid excessive fluid resuscitation that may worsen cerebral edema 4
• Do not rely on single hematocrit measurements as isolated markers for bleeding 1

Functional Outcome Assessment

• Assess functional outcome with modified Rankin Scale Score (mRSS) and Barthel Index at 7-10 days, 30 days, and 90 days 1
• Calculate IPH and FUNC scores to predict functional outcome 2
• Quality of life should be assessed at 90 days using standardized scales such as EuroQol 1
• Same blinded examiner should perform all follow-up evaluations 1