What is the management plan for an intracranial (within the skull) bleed?

Management of Intracranial Hemorrhage

Immediate Stabilization and Diagnosis

All patients with suspected intracranial hemorrhage require immediate admission to an acute stroke unit with comprehensive monitoring capabilities, as this represents the single most strongly supported intervention to improve outcomes. 1, 2

• Obtain non-contrast head CT immediately—this is the gold standard for confirming diagnosis and establishing baseline hematoma volume 1, 2
• Assess Glasgow Coma Scale (GCS) score on arrival, as this combined with hematoma volume represents the most powerful predictor of 30-day mortality 1, 2
• Monitor for early deterioration (occurs in >20% within first few hours), defined as GCS decrease ≥2 points 2
• Establish continuous monitoring of blood pressure, heart rhythm (1-lead ECG minimum), oxygen saturation, body temperature, and intermittent blood glucose 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, 4

• Avoid aggressive blood pressure reduction in patients with suspected elevated intracranial pressure (ICP), as this may compromise cerebral perfusion pressure 2
• For hemorrhagic stroke specifically, systolic blood pressures of 130-140 mmHg show optimal attenuation of hematoma growth 3
• Maintain euvolemia throughout treatment 2

Reversal of Anticoagulation

Warfarin-Associated ICH

Administer 4-factor prothrombin complex concentrate (PCC) immediately—this is superior to fresh frozen plasma for warfarin reversal in emergency settings. 3, 2

• PCC offers rapid reconstitution, smaller volume infusion (20-30 minutes), fast onset, no ABO compatibility requirement, and reduced risk of transfusion-related complications 3
• Discontinue warfarin immediately when intracranial hemorrhage is present or suspected 3
• Correct INR as rapidly as possible—ideally within 1.9 hours of presentation, with full correction within 4 hours 3

Novel Oral Anticoagulant (NOAC)-Associated ICH

• For dabigatran: Use idarucizumab 2
• For factor Xa inhibitors (rivaroxaban, apixaban): Use andexanet alfa 2

Low Molecular Weight Heparin (LMWH)-Associated ICH

Administer protamine sulfate by slow IV injection over 10 minutes according to specific dosing protocols. 3

• For enoxaparin given within 8 hours: 1 mg protamine per 1 mg enoxaparin (maximum 50 mg single dose) 3
• For enoxaparin given within 8-12 hours: 0.5 mg protamine per 1 mg enoxaparin 3
• For dalteparin, nadroparin, tinzaparin: 1 mg protamine per 100 anti-Xa units (maximum 50 mg) 3
• If life-threatening bleeding persists or patient has renal insufficiency, redose protamine at 0.5 mg per 100 anti-Xa units 3

Pentasaccharide-Associated ICH

• Administer activated prothrombin complex concentrate (aPCC) 20 IU/kg for reversal 3
• If aPCC contraindicated or unavailable, use recombinant factor VIIa (rFVIIa) 90 μg/kg 3
• Do not use protamine for pentasaccharide reversal 3

Thrombolytic-Associated ICH

Use cryoprecipitate (10 units initial dose) in patients with symptomatic ICH who received thrombolytics within the previous 24 hours. 3

• If cryoprecipitate contraindicated or unavailable, use tranexamic acid 10-15 mg/kg IV over 20 minutes OR ε-aminocaproic acid 4-5 g IV 3
• Check fibrinogen levels after reversal—if <150 mg/dL, administer additional cryoprecipitate 3

Antiplatelet-Associated ICH

Discontinue all antiplatelet agents immediately when intracranial hemorrhage is present or suspected. 3

• Do not transfuse platelets for antiplatelet-associated ICH in patients who will NOT undergo neurosurgical procedures, regardless of platelet inhibitor type, platelet function testing, hemorrhage volume, or neurologic examination 3
• Transfuse platelets for aspirin- or ADP inhibitor-associated ICH in patients who WILL undergo neurosurgical procedures 3
• Perform platelet function testing prior to transfusion if possible 3

Intracranial Pressure Management

Insert ICP monitoring device in patients with GCS ≤8, hydrocephalus, or clinical evidence of transtentorial herniation. 1, 2, 4

• Elevate head of bed to 30° with head midline to improve jugular venous outflow (only after excluding hypovolemia) 2
• Target cerebral perfusion pressure (CPP) ≥60-70 mmHg 2
• Use osmotic agents (mannitol or hypertonic saline) to produce hyperosmolality and euvolemia in patients with elevated ICP 4
• Monitor serum osmolarity when using osmotic agents 2
• Monitor renal function, as mannitol can cause renal failure, volume depletion, and rebound intracranial hypertension 2
• Ensure adequate analgesia and sedation 2
• Maintain normothermia or accept mild hypothermia from general anesthesia without aggressive rewarming 2
• Do not use acetazolamide in ICH management 4
• Do not use corticosteroids—these are specifically contraindicated 4

Surgical Intervention

Cerebellar Hemorrhage

Perform immediate surgical evacuation for cerebellar hemorrhage with ANY of the following: neurological deterioration, brainstem compression, hydrocephalus, or cerebellar ICH volume ≥15 mL. 3, 1, 2

• Ventricular catheter alone is insufficient and not recommended, especially in patients with compressed cisterns 3
• For cerebellar hemorrhage <3 cm diameter without brainstem compression or hydrocephalus, reasonable outcomes may be achieved without surgery 3

Supratentorial ICH

• Surgery remains uncertain for most patients with supratentorial ICH 2
• Consider early surgery for patients with GCS 9-12 2
• Patients with lobar hemorrhages extending to within 1 cm of cortical surface showed trend toward favorable outcome with surgery within 96 hours, though not statistically significant 3

Hydrocephalus and Intraventricular Hemorrhage

Ventricular drainage is reasonable for patients with decreased level of consciousness due to hydrocephalus. 3, 4

• Intraventricular administration of rt-PA appears to have fairly low complication rate but efficacy remains uncertain—considered investigational 3
• Consider decompressive craniectomy for patients with high ICP and mass effect 1, 2

Fluid Management

Use 0.9% normal saline as the crystalloid of choice to prevent worsening cerebral edema. 2, 4

• Maintain isotonicity and normoglycemia 2
• Exclude hypovolemia before elevating head of bed 2

Prevention of Secondary Complications

Venous Thromboembolism Prophylaxis

Apply intermittent pneumatic compression immediately for all immobile patients. 2

• Initiate pharmacological thromboprophylaxis within 24 hours after bleeding has stabilized 3, 2

Other Complications

• Monitor for and aggressively manage fever—postoperative hyperthermia is detrimental 2
• Monitor for pneumonia, cardiac events, and acute kidney injury 1, 2
• Consider seizure prophylaxis based on clinical presentation 2
• Monitor fluid and electrolyte balance, particularly sodium and potassium 2
• Maintain platelet count >50×10⁹/L in patients with ongoing bleeding 2

Specialized Nursing and Rehabilitation

Provide specialized stroke nursing care with formal training in stroke medicine. 3

• Focus on careful positioning, pressure-area risk evaluation, neurological monitoring using validated scales, fluid balance assessment, temperature monitoring, and dysphagia assessment 3
• Begin early mobilization (out of bed within 24 hours) once stroke has stabilized and medical condition permits 3
• Provide physical therapy at least once daily (7 days/week), preferably twice daily if resources permit 3

Special Populations

Cancer Patients with Intracranial Malignancies

Treat patients with primary or metastatic intracranial tumors using standard anticoagulation—small retrospective studies indicate this can be safely used. 3

• Anticoagulation with intravenous UFH followed by VKA or subcutaneous UFH has been associated with symptomatic intracranial hemorrhage rates between 0-7% 3
• LMWH shows similar safety profile with trend toward improved survival 3

Thrombocytopenia

• Therapeutic anticoagulation with LMWH may be administered if platelet count maintained >50×10⁹/L 3
• For platelet counts 20-50×10⁹/L, use half-dose LMWH with close follow-up 3
• If platelet count <20×10⁹/L, hold therapeutic anticoagulation 3

Restarting Anticoagulation After ICH

In patients with prosthetic valves, anticoagulation can safely be withheld for 7-14 days with very low probability of thromboembolic events. 5

• Heparin can safely be restarted as early as 3 days 5
• Switch to oral anticoagulation (warfarin) at 7 days without major bleeding concerns 5
• The risk of thromboembolism during reversal period is low (5%), as is rebleed incidence (0.5%) 5