What is the appropriate management for a patient with acute intraparenchymal hemorrhage in bilateral temporal lobes?

Management of Acute Bilateral Temporal Lobe Intraparenchymal Hemorrhage

Immediate admission to a neurointensive care unit with aggressive blood pressure control to systolic BP 140 mmHg, correction of any coagulopathy, serial neurological monitoring, and consideration for ICP monitoring if GCS ≤8 or clinical deterioration occurs. 1

Immediate Assessment and Stabilization

Neurological Evaluation

• Perform urgent Glasgow Coma Scale assessment, pupillary examination, and complete neurological examination to establish baseline 2
• Document GCS components (Eye, Motor, Verbal) and pupillary size/reactivity 3
• Calculate ICH score to stratify mortality risk 1

Vascular Imaging

• Obtain CT angiography (CTA) immediately to exclude underlying vascular malformation, aneurysm, or venous sinus thrombosis, particularly given the bilateral temporal location which is atypical for hypertensive hemorrhage 1
• If CTA suggests vascular anomaly, proceed to catheter angiography for definitive diagnosis and potential treatment 1

Blood Pressure Management

• Target systolic BP of 140 mmHg (strictly avoiding SBP <110 mmHg) if presenting within 6 hours of symptom onset 1
• Use IV beta blockers or calcium channel blockers for rapid control 4
• Maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion 2, 5

Coagulopathy Reversal

Anticoagulant-Associated Hemorrhage

• Discontinue all anticoagulation immediately 1
• For warfarin (INR ≥2.0): administer 4-factor prothrombin complex concentrate (4F-PCC) over fresh frozen plasma, plus IV vitamin K 1
• For dabigatran: administer idarucizumab 1
• For factor Xa inhibitors: administer andexanet alpha or 4F-PCC if unavailable 1
• For heparin: administer protamine sulfate 1

Antiplatelet Therapy

• Do not routinely transfuse platelets in patients taking aspirin or clopidogrel, as this has been shown to provide no benefit and may be harmful 6, 4
• Hold aspirin immediately upon diagnosis 3

Intracranial Pressure Management

ICP Monitoring Indications

• Consider ICP monitoring if GCS ≤8, clinical evidence of transtentorial herniation, or significant intraventricular extension with hydrocephalus 1
• Use intraparenchymal probes rather than ventricular catheters due to better risk-benefit profile (lower infection rate: 2.5% vs 10%; lower hemorrhage rate: 0-1% vs 2-4%) 1, 2
• Target cerebral perfusion pressure (CPP) of 60-70 mmHg; avoid CPP >70 mmHg due to increased risk of acute respiratory distress syndrome 1, 5

Hydrocephalus Management

• Place external ventricular drain urgently if decreased level of consciousness with CT evidence of hydrocephalus from intraventricular extension 1
• Ventricular drainage is reasonable for hydrocephalus treatment, especially with decreased consciousness 1

Serial Monitoring Protocol

Repeat Imaging

• Obtain repeat non-contrast head CT at 6-8 hours after initial scan to assess for hematoma expansion, as most expansion occurs within first 6 hours 3, 7
• Perform immediate CT if GCS declines by ≥2 points or new focal neurological deficits develop 3
• 96% of hemorrhages stop progressing by 24 hours and 99% by 48 hours 7

Neurological Monitoring

• GCS monitoring every 15 minutes for first 2 hours, then hourly for following 12 hours 3
• Continuous monitoring for signs of herniation (pupillary changes, posturing) 3
• Monitor for seizures clinically; consider continuous EEG if altered mental status 4

Surgical Considerations

Indications for Neurosurgical Consultation

• Significant mass effect with midline shift >5mm 1
• Progressive neurological deterioration despite medical management 1
• Posterior fossa hemorrhage with brainstem compression 1
• Large lobar hemorrhage (>30 mL) in superficial location with clinical deterioration 1

Minimally Invasive Approaches

• Stereotactically guided drainage with intraventricular hemorrhage has been shown safe and may improve outcomes 4
• Consider for select patients, particularly those with intraventricular extension 4

Critical Pitfalls to Avoid

• Do not administer corticosteroids for elevated ICP in intracerebral hemorrhage, as they do not improve outcomes and may worsen them 1, 3
• Do not delay correction of coagulopathy while awaiting family discussions or additional testing 5
• Do not administer long-acting sedatives or paralytics before establishing neurological monitoring baseline, as this masks clinical deterioration 3, 5
• Do not discharge patients with documented intraparenchymal hemorrhage based solely on normal neurological examination, as delayed deterioration can occur 3
• Avoid prophylactic antiepileptic drugs, as they confer no benefit 6

Disposition and Follow-Up

• Admit to neurointensive care unit or stroke unit for minimum 24-48 hours of observation 1, 3, 7
• Maintain euvolemia; avoid both hypovolemia and hypervolemia 1
• Thromboembolic prophylaxis with sequential compression devices once hemorrhage stabilized 6
• Consider repeat imaging at 4-6 weeks to ensure resolution or stability 2