What is the management of intracranial hemorrhage (ICH) resulting from a traumatic fall?

From the Guidelines

Management of intracranial hemorrhage (ICH) resulting from a traumatic fall is primarily focused on immediate diagnosis and stabilization. The initial assessment should include a CT or MRI to confirm the diagnosis, location, and extent of the hemorrhage 1.

Initial Assessment and Diagnosis

• Patients with suspected ICH should undergo a CT or MRI immediately to confirm diagnosis, location, and extent of hemorrhage 1.
• CT angiography, MR angiography, or catheter angiography is recommended for most patients to exclude an underlying lesion such as an aneurysm or arteriovenous malformation 1.
• Evaluation of patients with acute ICH should include questions about anticoagulant therapy, measurement of platelet count, partial thromboplastin time (PTT), and INR 1.

Risk of Delayed Hemorrhage

• The risk of delayed hemorrhage in patients on anticoagulants or antiplatelet agents is low, but not negligible 1.
• Studies suggest that delayed ICH after blunt head trauma in neurologically intact patients on anticoagulant or antiplatelet therapy is rare, and tends not to be clinically significant 1.
• However, clear discharge instructions with return precautions are warranted due to the potential for up to approximately 5% of these patients to develop delayed ICH 1.

Observation and Repeat Imaging

• The need for repeat imaging is debated, but most studies suggest that a brief observation period and repeat CT scan may not be necessary for all patients 1.
• Patients on anticoagulants, or antiplatelet agents, with a normal initial head CT after blunt trauma and who are neurologically intact can be safely discharged 1.
• The decision to withhold anticoagulant or antiplatelet medication should be made on a case-by-case basis, weighing the risk of repeat trauma or lack of good social support for home observation 1.

Categories of Intracranial Hemorrhage

• The term intracranial hemorrhage encompasses various subtypes, including noncoagulopathic spontaneous ICH, coagulopathic spontaneous ICH, noncoagulopathic traumatic intracranial hemorrhage, and coagulopathic traumatic intracranial hemorrhage 1.
• The pathobiology and risk of bleeding differ between traumatic and spontaneous bleeding, and between coagulopathic and noncoagulopathic bleeding 1.

From the Research

Management of Intracranial Hemorrhage

The management of intracranial hemorrhage (ICH) resulting from a traumatic fall involves several key strategies, including:

• Stabilization of breathing and circulation 2
• Control of increased intracranial pressure using osmotic agents, such as mannitol and glycerol 2
• Arterial blood pressure control, which requires adequate compliance to specific guidelines 2, 3
• Correction of coagulopathies and reversal of oral anticoagulation 3, 4, 5, 6
• Prevention of hematoma expansion and minimally invasive hematoma evacuation, which are promising therapeutic strategies under investigation 4, 5

Medical Management

Medical management of ICH includes:

• Blood pressure management to prevent further bleeding and minimize the risk of hematoma expansion 3, 5, 6
• Glycemic control to prevent hyperglycemia, which can worsen outcomes 5, 6
• Temperature control to prevent fever, which can also worsen outcomes 5, 6
• Seizure prevention and treatment to prevent secondary brain injury 5
• Deep venous thrombosis prophylaxis and treatment to prevent thromboembolic complications 5, 6

Surgical Management

Surgical management of ICH is controversial, but may include:

• Placement of a ventricular drain in patients with hydrocephalus 3
• Evacuation of a large posterior fossa hematoma 3
• Minimally invasive surgery for the management of ICH, which is an emerging area of research 5