What are the management strategies for intracranial hemorrhage?

Management of Intracranial Hemorrhage

Immediate Admission and Stabilization

All patients with intracranial hemorrhage must be admitted to an acute stroke unit or neuroscience intensive care unit, as this represents the single most strongly supported intervention to improve mortality and functional outcomes. 1, 2

• Obtain immediate non-contrast CT scan to confirm diagnosis, establish baseline hematoma volume, and predict 30-day mortality 2, 3
• Assess Glasgow Coma Scale (GCS) score immediately, as GCS combined with hematoma volume represents the most powerful predictor of mortality 2, 3
• Monitor for early deterioration (occurs in >20% within first hours), defined as GCS decrease ≥2 points 2, 3
• Provide ventilatory and cardiovascular support as needed 2, 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, 2

• This recommendation is based on moderate-quality evidence showing reduced hematoma expansion without compromising cerebral perfusion 1
• Avoid aggressive blood pressure reduction in patients with suspected elevated intracranial pressure (ICP), as this may compromise cerebral perfusion pressure (CPP) 2
• Maintain CPP ≥60 mmHg when managing ICP 1, 2
• Use continuous arterial monitoring in patients requiring IV antihypertensives or those with neurological deterioration 1

Reversal of Coagulopathy

For warfarin-associated ICH, administer prothrombin complex concentrate immediately—this is the fastest reversal method. 2, 3

• For dabigatran-associated ICH: use idarucizumab as the specific reversal agent 2, 3
• For factor Xa inhibitor-associated ICH: use andexanet alfa 2, 3
• For heparin-associated bleeding: administer protamine sulfate at 1 mg per 100 units of heparin given in previous 2-3 hours (maximum 50 mg single dose) 3
• Maintain platelet count >50×10⁹/L in patients with ongoing bleeding 2
• Do NOT routinely transfuse platelets in patients taking aspirin or clopidogrel without active bleeding 4

Intracranial Pressure Management

Insert ICP monitoring device in patients with GCS ≤8, hydrocephalus, or clinical evidence of transtentorial herniation. 2, 5, 3

• Elevate head of bed to 30° with head midline to improve jugular venous outflow 2, 3
• Use osmotic agents (mannitol or hypertonic saline) to produce hyperosmolality and euvolemia in patients with elevated ICP 5, 6
• Perform CSF drainage via external ventricular drainage for patients with hydrocephalus or ventricular obstruction 5
• Ensure adequate analgesia and sedation 2
• Maintain normothermia or accept mild hypothermia without aggressive rewarming 2

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, 2
• Consider decompressive craniectomy for patients with high ICP and mass effect 2
• Patients with hematomas extending to within 1 cm of cortical surface may benefit from surgery within 96 hours 3

Fluid Management

Use 0.9% normal saline as the crystalloid of choice to prevent worsening cerebral edema—avoid hypotonic fluids. 2, 5, 3

• Maintain isotonicity and normoglycemia 2, 5
• Maintain euvolemia throughout treatment 2
• Exclude hypovolemia before elevating head of bed, as this may decrease CPP 2

Prevention of Secondary Complications

Apply intermittent pneumatic compression immediately for venous thromboembolism prophylaxis in immobile patients. 1, 2, 3

• Initiate pharmacological thromboprophylaxis (LMWH or UFH) within 24-48 hours after bleeding has stabilized on repeat CT 1, 2
• Do NOT use graduated compression stockings—they are ineffective compared to intermittent pneumatic compression 1
• Monitor for and aggressively manage fever, as hyperthermia worsens outcomes 2
• Monitor for pneumonia, cardiac events, and acute kidney injury 2, 3

Contraindicated Interventions

Do NOT administer corticosteroids—they provide no benefit and may worsen outcomes. 1, 5

• Do NOT use recombinant factor VIIa routinely—it reduces hematoma expansion but does not improve outcomes and increases thromboembolic complications 4
• Do NOT use acetazolamide in ICH management 5
• Avoid medications that cause cerebral vasodilation or increase cerebral blood volume, as these worsen intracranial compliance and can precipitate herniation 5

Critical Monitoring Parameters

• Monitor neurological status frequently using standardized scales (NIHSS, GCS) 1
• Monitor fluid and electrolyte balance, particularly sodium and potassium 2
• Monitor serum osmolarity when using osmotic agents 2
• Monitor renal function, as mannitol can cause renal failure, volume depletion, and rebound intracranial hypertension 2
• Monitor CPP when managing ICP, targeting CPP ≥60-70 mmHg 2

Common Pitfalls to Avoid

• Do not delay coagulopathy reversal—immediate reversal is essential for anticoagulated patients 3
• Do not use hypotonic fluids, which worsen cerebral edema 2, 3
• Do not withhold VTE prophylaxis indefinitely—begin mechanical prophylaxis immediately and pharmacological prophylaxis within 24-48 hours after stability confirmed 1, 2
• Do not assume all ICH patients have poor prognosis—most present with small hemorrhages that are readily survivable with aggressive early care 3