What is the immediate management for a basal ganglia (intracerebral) hemorrhage?

Immediate Management of Basal Ganglia (Intracerebral) Hemorrhage

For patients with basal ganglia hemorrhage, immediately lower systolic blood pressure to 130-140 mmHg within 1 hour if presenting within 6 hours of symptom onset with SBP >150 mmHg and no planned immediate surgery, reverse any coagulopathy urgently, and admit to an intensive care unit or dedicated stroke unit with neuroscience expertise. 1, 2

Initial Assessment and Monitoring

• Perform immediate non-contrast CT scan to confirm intracerebral hemorrhage and assess hematoma volume, location, and presence of intraventricular extension 1
• Calculate a baseline severity score (Glasgow Coma Scale or NIHSS) as part of initial evaluation 1
• Admit to intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise for initial monitoring and management 1
• Establish continuous monitoring of blood pressure, neurological status, and vital signs 1

Blood Pressure Management

Intensive blood pressure lowering is the cornerstone of acute management for basal ganglia hemorrhage:

• For patients presenting within 6 hours with SBP 150-220 mmHg and no immediate surgery planned, acutely lower SBP to 130-140 mmHg within 1 hour using intravenous antihypertensive agents 1, 2
• This aggressive blood pressure control significantly reduces hematoma enlargement, cerebral edema, and improves neurological outcomes 2
• Use small boluses of labetalol for hypertension management, with increased sedation as needed 1
• Avoid hypotension (systolic <110 mmHg) as it can worsen secondary cerebral injury and adversely affect neurological outcome 1, 3
• Maintain SBP >100 mmHg or MAP >80 mmHg to ensure adequate cerebral perfusion 3

Reversal of Coagulopathy

Rapid reversal of anticoagulation is critical and takes precedence:

• For patients on warfarin with elevated INR, immediately administer prothrombin complex concentrate (PCC) plus intravenous vitamin K and withhold warfarin 1
• Do NOT use fresh frozen plasma (FFP) for warfarin reversal—PCC is superior as it rapidly reverses coagulopathy while limiting fluid volumes 1
• For patients with severe thrombocytopenia, administer platelet transfusion 1
• For patients with severe coagulation factor deficiency, provide appropriate factor replacement therapy 1

Fluid Management

Strict attention to fluid choice prevents worsening cerebral edema:

• Use 0.9% normal saline exclusively as the crystalloid of choice—it is the only commonly available isotonic crystalloid solution in terms of osmolality 1, 3
• Avoid hypotonic solutions including Ringer's lactate, Ringer's acetate, and gelatins, as these increase brain water content when real osmolality is measured 1, 3
• Do NOT use albumin or synthetic colloids in early management of brain-injured patients 1
• Maintain euvolemia through cautious use of isotonic fluids while preventing volume overload 1, 3

Management of Hypotension

If hypotension develops despite adequate fluid resuscitation:

• Correct hypovolemia first, then reassess sedation levels 1
• Administer small bolus of alpha-agonist (metaraminol) followed by infusion, or noradrenaline via central venous catheter only 1
• Never transfer a hypotensive, actively bleeding patient—bleeding control takes precedence over transfer 1

Venous Thromboembolism Prophylaxis

• Begin intermittent pneumatic compression on the day of hospital admission for DVT prevention 1
• Avoid graduated compression stockings in acute ICH 1

Glucose Management

• Monitor glucose levels closely and avoid both hyperglycemia and hypoglycemia 1

Seizure Management

• Treat clinical seizures immediately with antiseizure drugs 1
• For patients with altered mental status, perform EEG and treat electrographic seizures with antiseizure drugs 1
• Do NOT use prophylactic antiseizure drugs routinely unless seizures are documented 1

Aspiration Prevention

• Perform formal dysphagia screening before initiating any oral intake to reduce pneumonia risk 1

Surgical Considerations for Basal Ganglia Hemorrhage

Surgery for basal ganglia (supratentorial) hemorrhage remains controversial:

• For most patients with basal ganglia ICH, the usefulness of surgery is not well established 1
• Consider hematoma evacuation as a life-saving measure only in deteriorating patients 1
• Ultra-early craniotomy (within 4 hours) is associated with increased rebleeding risk and is not recommended 1
• Minimally invasive aspiration techniques show promise but effectiveness remains uncertain 1, 4
• Decompressive craniectomy with or without hematoma evacuation might reduce mortality for comatose patients with large hematomas, significant midline shift, or elevated ICP refractory to medical management 1

Management of Intraventricular Extension

If intraventricular hemorrhage is present:

• Consider external ventricular drainage for hydrocephalus 1
• Intraventricular thrombolysis remains investigational and should only be used in clinical trials 1

Critical Pitfalls to Avoid

• Do NOT delay blood pressure lowering beyond 6 hours of symptom onset—the therapeutic window is narrow 1, 2
• Do NOT use FFP for warfarin reversal—always use PCC to limit fluid volumes 1
• Do NOT use hypotonic crystalloids like Ringer's lactate—only 0.9% saline 1, 3
• Do NOT institute DNR orders or withdraw support in the first 48 hours—early prognostication is unreliable and creates self-fulfilling prophecies 1
• Do NOT perform ultra-early surgery (within 4 hours) due to increased rebleeding risk 1

Prognostication Caution

• Postpone DNR orders until at least the second full day of hospitalization unless pre-existing advance directives exist 1
• Provide aggressive guideline-concordant therapy for all patients without advance directives specifying otherwise 1
• Current prognostication methods are biased by failure to account for withdrawal of support and early DNR orders 1