What is the management plan for intracranial bleeding?

Management of Intracranial Bleeding

Admit all patients with intracranial hemorrhage (ICH) to an acute stroke unit for comprehensive monitoring and management, as this represents the single most strongly supported intervention to improve outcomes. 1

Initial Stabilization and Assessment

Obtain immediate non-contrast CT scan to confirm diagnosis and establish baseline hematoma volume, as this is the gold standard for identifying acute hemorrhage and predicting 30-day mortality. 2, 3

• Assess Glasgow Coma Scale (GCS) score on arrival, as this combined with hematoma volume represents the most powerful predictor of mortality 2, 3
• Evaluate for early deterioration, which occurs in over 20% of patients within the first few hours, manifesting as a GCS decrease of ≥2 points 3
• Provide immediate ventilatory and cardiovascular support as needed 3

Blood Pressure Management

Target systolic blood pressure <140 mmHg within 6 hours of symptom onset using intensive blood pressure lowering to prevent hematoma expansion. 1, 4

• Avoid aggressive blood pressure reduction in patients with suspected elevated intracranial pressure (ICP), as this may compromise cerebral perfusion pressure (CPP) 1
• Do not use medications that cause cerebral vasodilation or increase cerebral blood volume, as these worsen intracranial compliance and can precipitate herniation 4
• Maintain euvolemia throughout treatment 1

Reversal of Coagulopathy

For patients on warfarin with life-threatening ICH, administer prothrombin complex concentrate immediately to reverse anticoagulation as rapidly as possible. 4, 3

• For dabigatran-associated ICH, use idarucizumab 4
• For factor Xa inhibitor-associated ICH, use andexanet alfa 4
• Maintain platelet count >50×10⁹/L in patients with ongoing bleeding 3

Intracranial Pressure Management

Insert ICP monitoring device in patients with GCS ≤8, hydrocephalus, or clinical evidence of transtentorial herniation. 4, 2, 3

Stepwise ICP Management Algorithm:

1. First-line measures:

   • Elevate head of bed to 30° with head midline to improve jugular venous outflow 1
   • Ensure adequate analgesia and sedation 1
   • Maintain normothermia or accept mild hypothermia from general anesthesia without aggressive rewarming 1

2. Second-line measures for elevated ICP:

   • Administer osmotic agents (mannitol 0.25 g/kg every 6-8 hours IV over 30 minutes OR hypertonic saline) to produce hyperosmolality and euvolemia 4, 5
   • Perform CSF drainage via external ventricular drainage for patients with hydrocephalus or ventricular obstruction 4, 3
   • Maintain mild hypocapnia; avoid profound hypocapnia unless needed for acute brain swelling control 1

3. Avoid these interventions:

   • Do NOT use corticosteroids, as these are specifically contraindicated in ICH management 1, 4
   • Do NOT use acetazolamide 4
   • Avoid nonselective hyperventilation, as this may enhance secondary brain injury 1

Surgical Intervention

Perform immediate surgical evacuation for cerebellar hemorrhage with any of the following: neurological deterioration, brainstem compression, hydrocephalus, or cerebellar ICH volume ≥15 mL. 2, 3

• For supratentorial ICH, surgery remains uncertain for most patients, though consider early surgery for patients with GCS 9-12 1
• Hematomas extending to within 1 cm of the cortical surface may benefit from surgery within 96 hours 3
• Consider decompressive craniectomy for patients with high ICP and mass effect 2

Fluid Management

Use 0.9% normal saline as the crystalloid of choice to prevent worsening cerebral edema. 4

• Maintain isotonicity and normoglycemia 1
• Exclude hypovolemia before elevating head of bed, as this may decrease CPP 1

Prevention of Secondary Complications

Apply intermittent pneumatic compression immediately for venous thromboembolism prophylaxis in immobile patients. 1

• Do NOT use graduated compression stockings 1
• Initiate pharmacological thromboprophylaxis within 24 hours after bleeding has stabilized 3
• Monitor for and aggressively manage fever, as postoperative hyperthermia may be detrimental 1, 2
• Monitor for pneumonia, cardiac events, and acute kidney injury 2
• Consider seizure prophylaxis based on clinical presentation 2

Critical Monitoring Parameters

Monitor the following continuously in the intensive care unit:

• Fluid and electrolyte balance, particularly sodium and potassium, as imbalances can lead to encephalopathy or cardiac complications 4, 5
• Serum osmolarity when using osmotic agents 4, 5
• Renal function, as mannitol can cause renal failure, volume depletion, and rebound intracranial hypertension 1, 5
• Cardiac and pulmonary function 5
• CPP when managing ICP, targeting CPP ≥60-70 mmHg 1

Common Pitfalls to Avoid

• Avoid nephrotoxic drugs and other diuretics when using mannitol, as these increase risk of renal failure 5
• Avoid neurotoxic drugs when using mannitol, as these may potentiate CNS toxicity (confusion, lethargy, coma) 5
• Do not aggressively treat emergence hypertension after surgical intervention without considering the risk of hypoperfusion to marginally perfused areas 1
• Recognize that high mannitol concentrations may cause false low inorganic phosphorus results and false positive ethylene glycol results 5
• Monitor infusion sites carefully, as extravasation can cause severe reactions including compartment syndrome 5