What is the immediate management for a patient with intracranial and intraventricular hemorrhage with a significant midline shift?

Immediate Management of Intracranial and Intraventricular Hemorrhage with Significant Midline Shift

For patients with intracranial and intraventricular hemorrhage with significant midline shift, immediate neurosurgical consultation for decompressive craniectomy with or without hematoma evacuation should be pursued, as this intervention may reduce mortality in patients presenting with coma, large hematomas with significant midline shift, or elevated intracranial pressure refractory to medical management. 1, 2

Initial Stabilization and Assessment

Airway and Hemodynamic Management

• Secure the airway immediately with intubation and controlled mechanical ventilation targeting PaCO2 of 35 mmHg if the patient has impaired consciousness (GCS ≤8) or signs of herniation 1
• Place central venous and arterial catheters for hemodynamic monitoring 1
• Maintain cerebral perfusion pressure >60 mmHg (target 60-70 mmHg) through volume replacement and/or vasopressors as needed 1, 2

Blood Pressure Management

• Target systolic blood pressure <140 mmHg (strictly avoiding SBP <110 mmHg) if presenting within 6 hours of symptom onset to reduce hematoma expansion 1
• This aggressive blood pressure reduction is critical as elevated blood pressure is associated with hematoma growth 3

Coagulopathy Reversal

• Immediately discontinue and reverse anticoagulation if the patient is on anticoagulants 1
• For warfarin-associated ICH with INR ≥2.0: administer 4-factor prothrombin complex concentrate (4F-PCC) over fresh-frozen plasma, plus IV vitamin K 1
• For direct oral anticoagulants: use idarucizumab for dabigatran reversal or andexanet alpha (or 4F-PCC if unavailable) for factor Xa inhibitor reversal 1
• For heparin-related hemorrhage: administer protamine sulfate 1

Intracranial Pressure Management

ICP Monitoring

• Place an external ventricular drain (EVD) immediately for patients with intraventricular hemorrhage and hydrocephalus contributing to decreased level of consciousness 1
• ICP monitoring is indicated given the significant midline shift, particularly if GCS ≤8 3
• EVD placement is superior to medical management alone for reducing mortality in patients with large IVH and impaired consciousness 1

Medical ICP Management

• Initiate profound sedation and analgesia to facilitate mechanical ventilation 1
• Osmotherapy should be administered with target serum osmolality of 300-310 mOsmol/kg 1:
  • Mannitol 20% 1
  • Hypertonic saline solutions 1
• Important caveat: Osmotherapy efficacy is controversial in the setting of significant midline shift, as these agents may theoretically aggravate midline shift by reaching only regions with intact blood-brain barrier rather than ischemic areas 1

Surgical Intervention

Indications for Decompressive Craniectomy

• Decompressive craniectomy with or without hematoma evacuation is indicated for patients with 1, 2:
  • Coma presentation
  • Large hematomas with significant midline shift (>5 mm combined with hematoma thickness >10 mm) 2
  • Elevated ICP refractory to medical management 1
  • Neurological deterioration 2

Surgical Timing

• Surgery should be performed as soon as possible once clinical and radiological criteria are fulfilled 1
• Meta-analysis suggests surgery within 8 hours of hemorrhage may improve outcomes 1, 2
• Avoid ultra-early craniotomy within 4 hours due to increased rebleeding risk 1, 2

Surgical Technique

• For supratentorial hemorrhage: perform fronto-parieto-temporo-occipital craniectomy with diameter ≥12 cm, durotomy, and enlargement duroplasty 1
• Place intracranial pressure monitor during surgery 1, 2
• Hematoma evacuation may be performed if accessible, particularly for lobar hemorrhages within 1 cm of cortical surface 2

Special Consideration for Cerebellar Hemorrhage

• If cerebellar hemorrhage is present with brainstem compression or hydrocephalus, immediate surgical evacuation is mandatory (Class I recommendation) 1, 2
• Initial treatment with ventricular drainage alone rather than surgical evacuation is not recommended 1

Intraventricular Hemorrhage Management

EVD with Thrombolytic Therapy

• For patients with GCS >3 and IVH requiring EVD, minimally invasive IVH evacuation with EVD plus thrombolytic (alteplase or urokinase) is reasonable compared to EVD alone to reduce mortality 1
• This approach hastens intraventricular clot removal and provides additional mortality benefit beyond EVD alone 1

Critical Care Management

Monitoring and Prevention of Complications

• Perform serial neurological examinations and repeat head CT when clinically indicated 1
• Monitor body temperature and treat fever (>38°C) aggressively, investigating and treating sources 1
• Cardiac monitoring for at least 24 hours to screen for arrhythmias 1
• Initiate deep venous thrombosis prophylaxis with intermittent pneumatic compression devices immediately 1
• Antiseizure medications only for documented seizures, not prophylactically 1

Post-Surgical ICU Management

• Maintain normothermia (36-37°C) and blood glucose 6-10 mmol/L 2
• Continue ICP and CPP monitoring 2
• Obtain control CT at 24 hours or earlier if signs of intracranial hypertension develop 1
• Attempt weaning from sedation only when no signs of significant intracranial hypertension are present 1
• Monitor for complications including rebleeding, hydrocephalus, wound dehiscence, and meningitis 2

Key Clinical Pitfalls

Common errors to avoid:

• Delaying neurosurgical consultation—significant midline shift requires immediate surgical evaluation 1, 2
• Treating hydrocephalus with EVD alone without addressing mass effect from large hematoma—decompressive craniectomy may be necessary 1
• Over-aggressive blood pressure lowering causing SBP <110 mmHg, which can worsen cerebral perfusion 1
• Performing ultra-early surgery (<4 hours) without considering rebleeding risk 1, 2
• Using osmotherapy without monitoring serum osmolality, risking complications from hyperosmolality 1