What is the medical management for a patient with a cerebral contusion (bruise of the brain tissue) to the left side of the head, with potential complications such as intracranial hemorrhage or increased intracranial pressure, and a possible history of bleeding disorders or anticoagulant medication use?

Management of Left-Sided Cerebral Contusion

For a patient with a left-sided cerebral contusion (brain bruise), immediate priorities are maintaining systolic blood pressure >100 mmHg, securing the airway if Glasgow Coma Scale indicates severe injury, obtaining urgent neurosurgical consultation for life-threatening lesions, and reversing any anticoagulation immediately to prevent hematoma expansion. 1

Initial Assessment and Hemodynamic Stabilization

Airway and Ventilation Management:

• Secure the airway with tracheal intubation and mechanical ventilation with end-tidal CO2 monitoring if the Glasgow Coma Scale motor score indicates severe injury 2, 1
• Target PaCO2 between 35-40 mmHg to avoid hypocapnia, which causes cerebral vasoconstriction and worsens ischemia 2, 1
• Maintain PaO2 between 60-100 mmHg and oxygen saturation ≥94% 1, 3
• Critical pitfall: Never induce aggressive hypocapnia as it causes cerebral vasoconstriction and ischemia 1

Blood Pressure Management:

• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg to ensure adequate cerebral perfusion 1
• Avoid antihypertensive agents, particularly those that induce cerebral vasodilation, in patients with elevated intracranial pressure 2, 4
• An elevation in arterial blood pressure may be a compensatory response to maintain adequate cerebral perfusion pressure in patients with markedly elevated intracranial pressure 2

Immediate Coagulation Assessment and Reversal

Anticoagulant/Antiplatelet Verification:

• Immediately verify anticoagulant or antiplatelet medication use, as these medications increase hematoma expansion risk and mortality 2, 1, 5
• Patients on anticoagulants have a 3.9% risk of significant intracranial injury versus 1.5% in non-anticoagulated patients after blunt head trauma 2

Reversal Strategies:

• For warfarin-associated hemorrhage with INR ≥2.0: administer 4-factor prothrombin complex concentrate (4F-PCC) over fresh-frozen plasma, plus IV vitamin K to prevent re-emergence of anticoagulation 2
• For dabigatran: administer idarucizumab 2
• For factor Xa inhibitors: administer andexanet alpha or, if unavailable, 4F-PCC 2
• For heparin-related hemorrhage: administer protamine sulfate 2
• Maintain platelet count >50,000/mm³ and PT/aPTT <1.5 times normal control 1

Neuroimaging and Monitoring

Initial Imaging:

• Obtain non-contrast head CT immediately to assess contusion size, location, mass effect, and presence of associated hemorrhage 2, 1
• Consider CT angiography in patients <70 years with lobar hemorrhage or <45 years with deep/posterior fossa hemorrhage to exclude vascular anomalies 2

Serial Monitoring:

• Perform serial neurological assessments including continuous monitoring of Glasgow Coma Scale, pupillary responses, and focal neurological deficits 1
• Obtain repeat CT imaging if neurological deterioration occurs 1
• Cardiac monitoring is recommended for at least the first 24 hours to screen for arrhythmias 2

Management of Increased Intracranial Pressure

Initial Conservative Measures:

• Elevate the head of the bed 20-30 degrees to improve venous drainage and reduce intracranial pressure 2, 4
• Restrict fluids mildly and avoid hypo-osmolar fluids such as 5% dextrose in water, which worsen cerebral edema 2, 4
• Treat factors that exacerbate raised intracranial pressure: hypoxia, hypercarbia, and hyperthermia 2, 4
• Monitor body temperature and treat fever (>38°C) aggressively, investigating and treating sources of infection 2

Osmotic Therapy:

• Administer mannitol 0.25-0.5 g/kg IV every 6 hours (maximum 2 g/kg) for intracranial pressure management 1, 6
• When administering 25% mannitol, use a filter in the administration set and warm the solution if crystals are observed 6
• Monitor serum sodium and potassium carefully during mannitol administration, as excessive loss of water and electrolytes can lead to serious imbalances including hypernatremia 6
• Critical pitfall: Avoid concomitant administration of nephrotoxic drugs or other diuretics with mannitol due to increased risk of renal failure 6

Surgical Indications

Urgent Neurosurgical Consultation Required For:

• Subdural hematoma thickness >5 mm with midline shift >5 mm 2, 1
• Symptomatic extradural hematoma regardless of location 2, 1
• Open displaced skull fracture requiring closure 2, 1
• Closed displaced skull fracture with brain compression (thickness >5 mm, mass effect with midline shift >5 mm) 2
• Acute hydrocephalus requiring drainage 2
• Critical pitfall: Never delay surgical intervention in symptomatic patients, as this leads to neurological deterioration and worse outcomes 1

External Ventricular Drainage:

• Consider external ventricular drainage for persisting intracranial hypertension despite sedation and correction of secondary brain insults 2, 1
• In cases of intraventricular hemorrhage with hydrocephalus contributing to decreased level of consciousness, external ventricular drainage is recommended 2
• Note that external ventricular drain insertion is high-risk in the setting of coagulopathy and systemic anticoagulation 2

Decompressive Craniectomy:

• Consider decompressive craniectomy for refractory intracranial hypertension in multidisciplinary discussion 2
• Large temporal craniectomy (>100 cm²) with enlarged dura mater plasty is the most commonly used technique 2

Medical Management for Non-Surgical Cases

Conservative Management:

• Conservative management is appropriate when no signs of intracranial hypertension or neurological deterioration exist 1
• Administer aspirin 160-300 mg/day within 24-48 hours after stroke onset (generally delayed >24 hours if thrombolysis given) for ischemic components 2
• Antiseizure medications are only indicated for documented secondary seizures, not prophylactically 2

Prevention of Complications:

• Implement early mobilization and measures to prevent subacute complications including aspiration, malnutrition, pneumonia, deep vein thrombosis, pulmonary embolism, pressure sores, and contractures 2
• Use subcutaneous anticoagulation or intermittent external compression stockings for deep vein thrombosis prophylaxis in immobilized patients 2
• For patients who cannot receive anticoagulants, use aspirin or intermittent pneumatic compression devices 2
• Avoid indwelling bladder catheters when possible due to infection risk; consider intermittent catheterization or acidification of urine 2

Infection Management:

• Promptly investigate fever and administer appropriate antibiotics early for pneumonia or urinary tract infections 2
• Pneumonia is an important cause of death following brain injury and usually occurs in immobile patients or those unable to cough 2

Specific Considerations for Cerebral Contusions

Natural History:

• Brain edema typically peaks at 3-5 days after injury, though it is usually not problematic within the first 24 hours except in large cerebellar infarctions 2
• Less than 10-20% of patients develop clinically significant edema warranting medical intervention 2
• Hemorrhagic transformation occurs spontaneously in approximately 5% of cases, with location, size, and etiology influencing development 2

Seizure Management:

• Seizures occur in 4-43% of patients during the first days after injury, most likely within 24 hours 2
• Seizures are usually partial with or without secondary generalization 2
• Recurrent seizures develop in approximately 20-80% of patients who experience an initial seizure 2
• Status epilepticus is uncommon but life-threatening when it occurs 2

Contraindications to Specific Therapies:

• Never use corticosteroids for brain swelling management in traumatic brain injury 1
• No evidence indicates that hyperventilation, corticosteroids, diuretics, mannitol, or glycerol alone improve outcomes in patients with ischemic brain swelling 4

Comprehensive Stroke Unit Care

• Admit patients to a specialized stroke unit or, if critically ill, to an intensive care unit 2
• Use comprehensive specialized stroke care units incorporating comprehensive rehabilitation 2
• Implement gradual early mobilization as tolerated 2