What is the management approach for a patient with weakness 2 weeks after a fall that resulted in an intracranial hemorrhage?

Management of Weakness 2 Weeks After Fall-Related Intracranial Hemorrhage

For a patient presenting with weakness 2 weeks after a fall-related intracranial hemorrhage, immediate neuroimaging with non-contrast CT is mandatory to assess for delayed complications including hematoma expansion, hydrocephalus, or new bleeding, followed by urgent neurosurgical consultation if deterioration is occurring. 1, 2

Immediate Assessment and Diagnostic Workup

Neurological Evaluation

• Perform urgent neurological assessment including Glasgow Coma Scale, pupillary examination, and focal deficits to determine if the patient is deteriorating 2, 3
• Document the timeline and progression of weakness onset relative to the initial injury 1
• Assess for signs of increased intracranial pressure including altered consciousness, headache progression, or new neurological deficits 1, 2

Emergency Imaging

• Obtain non-contrast CT brain immediately without delay to evaluate for delayed hematoma expansion, new hemorrhage, hydrocephalus, or mass effect 4, 2
• Consider CT angiography if vascular abnormality (arteriovenous malformation, aneurysm, cortical vein thrombosis) is suspected, particularly in younger patients or atypical presentations 1
• MRI with gradient-echo sequences may identify cortical vein thrombosis presenting as delayed hemorrhage, which can manifest with ipsilateral dural thickening and enhancement 1

Critical Management Priorities

Hemodynamic Management

• Maintain systolic blood pressure >100-110 mmHg or mean arterial pressure >80 mmHg to ensure adequate cerebral perfusion pressure 4, 2, 3
• If intracranial pressure monitoring is available, target cerebral perfusion pressure ≥60 mmHg 1, 4, 3
• Even a single episode of hypotension markedly worsens neurological prognosis in patients with intracranial hemorrhage 4

Airway Protection

• Secure airway via endotracheal intubation for patients with GCS ≤8 4, 2
• Maintain PaO₂ between 60-100 mmHg and PaCO₂ between 35-40 mmHg to prevent cerebral vasoconstriction 2, 3

Coagulopathy Assessment and Reversal

• Immediately discontinue all antithrombotic agents if intracranial hemorrhage is present or suspected 1
• Check coagulation parameters (PT/INR, aPTT, platelet count) and reverse any coagulopathy 1, 4
• For warfarin-associated hemorrhage, administer prothrombin complex concentrate or fresh frozen plasma plus vitamin K 1
• Maintain platelet count >50,000/mm³, with higher targets advisable for neurosurgical intervention 3

Specific Clinical Scenarios Requiring Urgent Intervention

Deteriorating Neurological Status

• If the patient is deteriorating neurologically with evidence of mass effect or hematoma expansion, urgent neurosurgical consultation is mandatory 1, 4, 2
• Craniotomy for hematoma evacuation may be considered as a life-saving measure in deteriorating patients, despite unclear overall functional benefit 1
• The STICH II trial demonstrated a 21% crossover rate from medical to surgical management due to deterioration, suggesting surgery may provide mortality benefit in this subset 1

Cerebellar Hemorrhage

• For cerebellar hemorrhage with neurological deterioration, brainstem compression, hydrocephalus, or volume ≥15 mL, immediate surgical evacuation with or without external ventricular drain is recommended to reduce mortality 1
• External ventricular drain alone may be insufficient or potentially harmful when basal cisterns are compressed 1

Hydrocephalus

• Ventricular drainage is reasonable for hydrocephalus in patients with decreased level of consciousness 1, 2
• Consider external ventricular drain placement for obstructive hydrocephalus 4, 3

Delayed Complications to Consider

Cortical Vein Thrombosis

• Isolated cortical vein thrombosis can present with delayed hemorrhage 2 weeks post-injury, manifesting as progressive weakness, headache, and seizures 1
• The mean time between symptom appearance and diagnosis is 7 days, making this a relevant consideration for delayed presentations 1
• Look for ipsilateral dural thickening and enhancement on MRI, which may indicate underlying cortical vein thrombosis 1
• Digital subtraction angiography remains the gold standard for confirming cortical vein thrombosis when CT or MRI findings are suspicious 1

Seizure Management

• Administer levetiracetam 1 g loading dose for seizure prophylaxis in high-risk patients (those with cortical involvement or prior seizures) 4
• Prophylactic antiepileptic drugs do not confer benefit in all patients and should be targeted to high-risk cases 5

Supportive Care Measures

Temperature and Metabolic Control

• Maintain normothermia (36-37°C) as hyperthermia worsens neurological outcomes 4, 2
• Optimize glucose control as hyperglycemia worsens neurological outcomes 4

Thromboprophylaxis

• Implement mechanical thromboprophylaxis with intermittent pneumatic compression as soon as possible 2
• Consider pharmacological thromboprophylaxis within 24 hours after bleeding has been controlled and stabilized 2

Critical Pitfalls to Avoid

• Never delay transfer to a specialized neurosurgical center for "stabilization" in a facility without neurosurgery 4
• Do not delay imaging while "observing" a patient with new or progressive weakness, as this increases mortality risk 4
• Avoid early pessimistic prognostication that may lead to premature withdrawal of aggressive care in patients who still have possibilities of favorable outcome 2
• Do not rely solely on clinical characteristics to determine hemorrhage stability; neuroimaging is mandatory 2

Disposition and Ongoing Management

• All patients with intracranial hemorrhage and new neurological symptoms require admission to a neurointensive care unit or neurosurgical service 1, 5
• Management in a specialized neurointensive care unit reduces mortality rates 1, 5
• Institute intracranial pressure monitoring post-operatively if surgery is performed, targeting ICP <20-22 mmHg 4
• Most functional and cognitive recovery occurs weeks to months after discharge, requiring comprehensive rehabilitation planning 6