What is the management and treatment for a patient with an intracranial (IC) hemorrhage (bleed)?

Management of Intracranial Hemorrhage

Immediate aggressive management of intracranial hemorrhage requires rapid neuroimaging, blood pressure control to systolic <160 mmHg (if no immediate surgery planned), immediate reversal of any coagulopathy, and surgical evacuation for cerebellar hemorrhages with neurological deterioration or brainstem compression. 1, 2

Initial Assessment and Stabilization

Obtain CT scan immediately – this is the gold standard for diagnosing acute intracranial hemorrhage and cannot be delayed, as clinical features alone cannot distinguish hemorrhagic from ischemic stroke. 1, 2 MRI is an alternative but CT is faster and more practical in the emergency setting. 1

Anticipate early deterioration – over 20% of patients experience a decrease in Glasgow Coma Scale (GCS) of ≥2 points between prehospital assessment and emergency department evaluation. 1, 2 This deterioration is driven by ongoing bleeding that can continue for hours after symptom onset. 2

Provide immediate ventilatory and cardiovascular support and transport to a facility equipped for acute stroke care with neurosurgical capabilities. 1, 2

Blood Pressure Management

For spontaneous ICH presenting within 6 hours with systolic BP >150 mmHg, aggressively reduce blood pressure to maintain systolic <160 mmHg if immediate surgery is not planned. 1, 2 This is critical because hypertension drives hematoma expansion, which directly predicts clinical deterioration and mortality. 1, 2

For unsecured aneurysms, maintain systolic BP <160 mmHg while avoiding hypotension (systolic <110 mmHg). 1 The balance here is preventing rebleeding without compromising cerebral perfusion.

Common pitfall: Elevated systolic BP (often >220 mmHg) is frequently seen in ICH and may represent a physiologic response to increased intracranial pressure – however, aggressive reduction is still indicated to prevent hematoma expansion. 3

Reversal of Coagulopathy

Immediately reverse anticoagulation – this is non-negotiable for patients on anticoagulants with ICH. 1, 2

Specific Reversal Protocols:

Vitamin K antagonists (warfarin):

• Administer four-factor prothrombin complex concentrate (PCC) plus vitamin K. 1
• Correct INR as rapidly as possible. 2, 3

Direct thrombin inhibitors (dabigatran):

• Administer idarucizumab (specific reversal agent). 1
• If unavailable, consider hemodialysis. 1

Factor Xa inhibitors (rivaroxaban, apixaban):

• Administer four-factor PCC at 50 U/kg or activated PCC at 50 U/kg. 1
• Alternatively, use aPCC (20 IU/kg) for pentasaccharides (fondaparinux). 4

Low molecular weight heparin (LMWH):

• For enoxaparin given within 8 hours: protamine sulfate 1 mg per 1 mg of enoxaparin (maximum 50 mg single dose). 4
• For enoxaparin given 8-12 hours prior: protamine 0.5 mg per 1 mg of enoxaparin. 4
• For dalteparin, nadroparin, tinzaparin: protamine 1 mg per 100 anti-Xa units (maximum 50 mg). 4
• Administer by slow IV injection over 10 minutes. 4

Unfractionated heparin:

• Protamine sulfate 1 mg for every 100 units of heparin given in the previous 2-3 hours (maximum 50 mg single dose). 1

Thrombolytic agents (if given within 24 hours):

• Administer cryoprecipitate 10 units initial dose. 4
• If cryoprecipitate unavailable: tranexamic acid 10-15 mg/kg IV over 20 minutes or ε-aminocaproic acid 4-5 g IV. 4
• Check fibrinogen after reversal; if <150 mg/dL, give additional cryoprecipitate. 4

Antiplatelet agents:

• Discontinue immediately. 4
• Do NOT transfuse platelets for patients who will not undergo neurosurgical procedure, regardless of antiplatelet type or hemorrhage volume. 4
• DO transfuse platelets for patients on aspirin or ADP inhibitors who will undergo neurosurgical procedure. 4
• Perform platelet function testing prior to transfusion if possible. 4

Management of Increased Intracranial Pressure

Elevate head of bed to 30 degrees for all patients with evidence of increased ICP. 1

Avoid hypotonic fluids – use 0.9% saline as the crystalloid solution. 1

Consider ICP monitoring for patients with GCS ≤8, hydrocephalus, or clinical evidence of transtentorial herniation. 1, 2, 3

Treatment options for elevated ICP:

• Osmotic agents (mannitol or hypertonic saline to achieve hyperosmolar euvolemic state). 1, 5, 6
• CSF drainage via intraventricular catheter. 1
• Hyperventilation (temporary measure only, as prolonged use reduces cerebral perfusion). 1, 5, 6

Ventricular drainage is reasonable for patients with hydrocephalus and decreased level of consciousness. 4

Intraventricular rt-PA for intraventricular hemorrhage appears to have low complication rates but efficacy remains uncertain – consider investigational only. 4

Surgical Management

Immediate surgical evacuation is indicated for cerebellar hemorrhage with:

• Neurological deterioration, OR
• Brainstem compression, OR
• Hydrocephalus from ventricular obstruction. 4, 1, 2, 3

Critical distinction: For cerebellar hemorrhage <3 cm diameter without brainstem compression or hydrocephalus, reasonable outcomes may be achieved without surgery. 4 However, ventricular catheter alone is insufficient for larger cerebellar hemorrhages with mass effect. 4

For supratentorial ICH, the benefit of surgery remains uncertain for most patients. 4, 2 However, patients with hematomas extending to within 1 cm of the cortical surface showed a trend toward better outcomes with surgery within 96 hours, particularly those with lobar hemorrhages and GCS 9-12. 4, 2

Prevention of Secondary Complications

Initiate deep venous thrombosis prophylaxis with intermittent pneumatic compression once bleeding has stabilized. 1, 2, 3

Monitor and manage medical complications including pneumonia, cardiac events (myocardial stunning is common), acute kidney injury, and pulmonary edema. 1, 2, 3, 7

Manage fever aggressively – fever is common (often not from infection) and should be treated, though therapeutic cooling has not shown benefit. 7

ICU admission is recommended for close monitoring of vital signs and neurological status. 1

Prognostic Factors

The volume of ICH and admission GCS score are the most powerful predictors of 30-day mortality. 1, 2, 3 However, most patients present with small ICHs that are readily survivable with good medical care, warranting early aggressive treatment. 1, 2, 3

Do-not-resuscitate status increases predicted mortality for any level of ICH severity, highlighting how goals of care impact outcomes. 7

Most functional and cognitive recovery occurs weeks to months after discharge, not in the acute phase. 7

Long-term Prevention

Hypertension treatment is the most critical target for preventing ICH recurrence – treated hypertension has an odds ratio of only 1.4 compared to 3.5 for untreated hypertension. 1

Strongly discourage smoking, heavy alcohol use, and cocaine use after ICH. 1

Advanced age (>65 years) increases risk of ICH recurrence. 1