What is the immediate management for intraparenchymal brain hemorrhage?

Immediate Management of Intraparenchymal Brain Hemorrhage

Treat intraparenchymal brain hemorrhage as a medical emergency requiring immediate stabilization, rapid blood pressure control to systolic 130-150 mmHg, urgent reversal of any coagulopathy, and prompt neurosurgical consultation for life-threatening lesions. 1, 2

Initial Stabilization and Assessment

Airway, Breathing, and Circulation (ABCs) take absolute priority:

• Secure the airway via tracheal intubation for patients with Glasgow Coma Scale (GCS) ≤8 2
• Maintain arterial partial pressure of oxygen (PaO₂) between 60-100 mmHg 3, 1, 2
• Maintain arterial partial pressure of carbon dioxide (PaCO₂) between 35-40 mmHg to prevent cerebral vasoconstriction and brain ischemia 3, 1, 2
• Maintain systolic blood pressure (SBP) >100 mmHg or mean arterial pressure (MAP) >80 mmHg during initial resuscitation 3, 2

Immediate diagnostic evaluation:

• Obtain non-contrast head CT scan immediately to confirm diagnosis, location, and extent of hemorrhage 1, 2
• Perform rapid neurological examination using standardized scales (NIHSS, GCS motor score) 1, 2
• Order urgent laboratory work: complete blood count, coagulation studies (PT/INR, aPTT), platelet count, type and cross-match 1
• Review medication history focusing on anticoagulants and antiplatelet agents 1

Blood Pressure Management

Target systolic blood pressure of 130-150 mmHg immediately:

• For patients with SBP 150-220 mmHg without contraindications, acute lowering to 140 mmHg is safe and improves functional outcomes 1
• Use rapid-onset, short-duration agents (labetalol in small boluses) to facilitate titration 3, 1
• Avoid aggressive blood pressure reduction below 130 mmHg systolic, as this is potentially harmful 3
• Monitor blood pressure every 15 minutes until stabilized 1

The rationale: Elevated blood pressure is associated with hematoma expansion, which occurs in 30-40% of patients and predicts poor outcome 1. However, excessive reduction compromises cerebral perfusion pressure.

Reversal of Coagulopathy

Immediately reverse anticoagulation to prevent hematoma expansion:

For warfarin with elevated INR:

• Administer four-factor prothrombin complex concentrate when INR ≥2.0 3, 1
• Give intravenous vitamin K immediately after prothrombin complex concentrate to prevent later INR increase 3, 1

For direct oral anticoagulants (DOACs):

• Administer specific antidote immediately (idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors) 3
• If specific antidote unavailable, use (activated) prothrombin complex concentrate 3

For heparin (unfractionated or low-molecular-weight):

• Administer intravenous protamine sulfate 3

For antiplatelet therapy:

• Do NOT administer platelet transfusions, as randomized trial data show worse outcomes 3
• Maintain platelet count >50,000/mm³ if neurosurgical intervention is anticipated 3

Management of Intracranial Pressure

Consider ICP monitoring for patients at risk:

• Patients with GCS ≤8, clinical evidence of transtentorial herniation, or significant intraventricular hemorrhage/hydrocephalus should be considered for ICP monitoring 3
• Maintain cerebral perfusion pressure (CPP) 50-70 mmHg, ideally ≥60 mmHg 3
• Elevate head of bed 20-30 degrees to facilitate venous drainage 1

Treatment of elevated ICP:

• Treat exacerbating factors: hypoxia, hypercarbia, hyperthermia 1
• Use osmotherapy (mannitol or hypertonic saline) for patients deteriorating from increased ICP 1
• In cases of cerebral herniation, use osmotherapy and/or temporary hypocapnia while awaiting emergency neurosurgery 3
• Avoid antihypertensive agents that cause cerebral vasodilation in patients with markedly elevated ICP 1

Fluid Management

Use only isotonic fluids:

• Maintain hydration with isotonic crystalloids while preventing volume overload 1
• Avoid hypotonic fluids (5% dextrose in water, Ringer's lactate, Ringer's acetate, gelatins) as they worsen cerebral edema 1
• Do not use albumin or synthetic colloids in early management 1

Neurosurgical Consultation and Intervention

Obtain urgent neurosurgical consultation for all patients:

• After control of life-threatening systemic hemorrhage, all salvageable patients with life-threatening brain lesions require urgent neurosurgical intervention 3, 2
• Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus require immediate surgical evacuation 1, 2
• For supratentorial hemorrhages, surgical evacuation is generally not beneficial except for selected patients with large lesions causing impending herniation 3
• Consider ventriculostomy for hydrocephalus from intraventricular extension 3

Seizure Management

Treat seizures appropriately but avoid prophylaxis:

• Treat new-onset seizures within 24 hours with appropriate short-acting medications 1
• Do NOT use prophylactic anticonvulsants, as they are not recommended 1
• Single, self-limiting seizures at onset should not receive long-term anticonvulsant therapy 1

Monitoring and Supportive Care

Intensive monitoring in specialized unit:

• Admit to intensive care unit or dedicated stroke unit with neuroscience expertise 1, 2
• Perform validated neurological assessments at baseline and at least hourly for first 24 hours 1
• Implement intermittent pneumatic compression for venous thromboembolism prophylaxis beginning day of admission 1
• Conduct formal dysphagia screening before oral intake 1

Critical Pitfalls to Avoid

Early deterioration is common and must be anticipated:

• Hematoma expansion occurs in 30-40% of patients, typically within first few hours 1
• Avoid early pessimistic prognostication that leads to self-fulfilling prophecies by limiting aggressive care 2
• Do not delay imaging or treatment decisions while awaiting diagnostic results 1
• Do not transfer hypotensive, actively bleeding patients; control hemorrhage first 1
• Recognize that very intense blood pressure lowering below 130 mmHg systolic is potentially harmful 3
• Be aware that patients on antiplatelet agents have higher risk of hematoma expansion despite other interventions 4