What are the criteria for neurointervention in a patient with a neurobleed (intracranial hemorrhage)?

Criteria for Neurointervention in Intracranial Hemorrhage

All salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation and intervention after control of any life-threatening systemic hemorrhage. 1

Initial Assessment Algorithm

The decision for neurointervention follows a structured priority sequence:

Step 1: Control Life-Threatening Systemic Hemorrhage First

• Patients with exsanguinating hemorrhage require immediate intervention (surgery and/or interventional radiology) for bleeding control before addressing intracranial pathology. 1
• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during hemorrhage control interventions. 1

Step 2: Urgent Neurological Evaluation

Once systemic bleeding is controlled (or if no life-threatening systemic hemorrhage exists):

• Perform urgent neurological evaluation including pupillary assessment and Glasgow Coma Scale motor score (if feasible). 1
• Obtain immediate brain CT scan to determine severity of brain damage and identify life-threatening lesions. 1

Step 3: Determine Need for Neurosurgical Intervention

Life-threatening brain lesions requiring urgent neurosurgical consultation include: 1

Specific Indications for Surgical Intervention:

• Cerebellar hemorrhage with neurological deterioration, brainstem compression, and/or hydrocephalus from ventricular obstruction requires surgical evacuation. 2
• Patients with intracranial mass lesions causing significant mass effect or midline shift. 1
• Patients showing signs of impending herniation. 1

ICP Monitoring Criteria (Without Immediate Surgical Evacuation):

• Comatose patients with radiological signs of intracranial hypertension (without a life-threatening mass lesion or after emergency neurosurgery) require ICP monitoring regardless of need for emergency extra-cranial surgery. 1
• Maintain cerebral perfusion pressure ≥60 mmHg when ICP monitoring is available. 1

Perioperative Management Requirements

Hemodynamic Targets:

• Maintain SBP >100 mmHg or MAP >80 mmHg during emergency neurosurgery. 1
• Lower values may be tolerated only for the shortest possible time during difficult intraoperative bleeding control. 1

Coagulation Parameters:

• Maintain platelet count >50,000/mm³ for emergency neurosurgery (including ICP probe insertion); higher values are advisable. 1
• Maintain PT/aPTT <1.5 times normal control during emergency neurosurgery. 1
• Utilize point-of-care testing (TEG/ROTEM) if available to optimize coagulation function. 1

Antiplatelet Reversal for Surgery:

• Platelet transfusion is suggested for patients with aspirin- or ADP inhibitor-associated ICH who will undergo neurosurgical procedures. 1
• Perform platelet function testing prior to transfusion if possible; avoid transfusion if platelet function is within normal limits. 1
• Initial dose: one single donor apheresis unit of platelets. 1

Respiratory Parameters:

• Maintain PaO₂ between 60-100 mmHg during emergency neurosurgery. 1
• Maintain PaCO₂ between 35-40 mmHg during emergency neurosurgery. 1

Transfusion Thresholds:

• Transfuse RBCs for hemoglobin <7 g/dL during emergency neurosurgery. 1
• Higher thresholds may be used in elderly patients or those with limited cardiovascular reserve. 1

Emergency Temporizing Measures

For cerebral herniation awaiting or during emergency neurosurgery: 1

• Use osmotherapy (mannitol 0.25-2 g/kg IV over 30-60 minutes). 3
• Consider temporary hypocapnia (PaCO₂ temporarily reduced below 35 mmHg). 1

Critical Pitfalls to Avoid

• Do not delay neurosurgical consultation while attempting medical management alone in patients with life-threatening mass lesions. 1
• Do not allow hypotension (SBP <100 mmHg) or hypoxia (PaO₂ <60 mmHg), which worsen secondary brain injury. 2, 4
• Do not insert ICP monitors without correcting coagulopathy (platelets >50,000/mm³, PT/aPTT <1.5 times control). 1
• Mannitol may increase cerebral blood flow and risk of postoperative bleeding in neurosurgical patients; use judiciously. 3
• Mannitol may worsen intracranial hypertension in children with generalized cerebral hyperemia during the first 24-48 hours post-injury. 3