What are the guidelines for managing a patient with a brainstem bleed?

Management of Brainstem Hemorrhage

Brainstem hemorrhage requires immediate intensive care monitoring with aggressive medical management prioritized over surgical intervention in most cases, except for cerebellar hemorrhages causing brainstem compression which mandate urgent surgical evacuation. 1

Initial Emergency Assessment and Stabilization

Rapid neuroimaging with CT scan is mandatory to confirm brainstem hemorrhage, assess hematoma volume and location, and identify mass effect or hydrocephalus. 1, 2 Perform baseline severity assessment using Glasgow Coma Scale (GCS), as GCS >8 at presentation is associated with better outcomes at three months. 3

Airway Management

• Secure the airway via endotracheal intubation for patients with GCS ≤8 to prevent aspiration and ensure adequate oxygenation. 4, 2 Patients with medullary hemorrhage are at particularly high risk for sudden respiratory arrest and require careful observation. 5
• Maintain PaO₂ between 60-100 mmHg and PaCO₂ between 35-40 mmHg to prevent cerebral vasoconstriction and brain ischemia. 4, 2, 6

Hemodynamic Management

Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during initial stabilization. 1, 2, 6 For patients presenting with SBP between 150-220 mmHg without contraindications, acute lowering of SBP to 140 mmHg is safe and can improve functional outcomes. 1

Coagulopathy Reversal

• For patients on vitamin K antagonists with elevated INR: immediately withhold VKA, administer therapy to replace vitamin K-dependent factors (prothrombin complex concentrates preferred), and give intravenous vitamin K. 1
• Patients with severe thrombocytopenia should receive platelet transfusions; those with severe coagulation factor deficiency require appropriate factor replacement. 1

Intensive Care Unit Management

All brainstem hemorrhage patients require admission to an intensive care unit or dedicated stroke unit with neuroscience expertise. 1 Mean ICU stay for brainstem hemorrhage is approximately 17 days with mean hospital stay of 58 days. 3

Monitoring and Medical Therapy

• Monitor glucose levels closely and avoid both hyperglycemia and hypoglycemia. 1
• Treat clinical seizures with antiseizure drugs; patients with altered mental status and electrographic seizures on EEG should also receive antiseizure treatment. 1 Prophylactic anticonvulsants are not recommended. 1
• Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk. 1

Venous Thromboembolism Prevention

Initiate intermittent pneumatic compression for VTE prevention beginning on the day of hospital admission. 1 Pharmacological thromboprophylaxis can be considered after bleeding stabilization. 4, 2

Surgical Considerations

Cerebellar Hemorrhage with Brainstem Compression

Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible. 1, 2 This is a Class I, Level of Evidence B recommendation and represents the clearest surgical indication in posterior fossa hemorrhage.

Primary Brainstem Hemorrhage

For hemorrhages confined to the brainstem (pons, midbrain, medulla), surgical intervention is generally not recommended as the primary treatment approach. 7 The indication for surgery in brainstem cavernous malformations is controversial, with most experts recommending observation after a single symptomatic bleed. 8 Surgery may be considered after a second hemorrhagic event in carefully selected patients with accessible lesions. 1, 8

Prognostication and Goals of Care

Avoid early pessimistic prognostication during the first 48-72 hours, as this can lead to premature withdrawal of care and self-fulfilling prophecies of poor outcome. 1 Aggressive full care early after hemorrhage onset and postponement of new DNR orders until at least the second full day of hospitalization is recommended. 1

Prognostic Factors

• GCS >8 at presentation is the strongest predictor of favorable outcome. 3
• Brainstem hemorrhage carries high morbidity and mortality, with approximately 20% mortality and 50% of survivors having moderate to severe disability (mRS 3-5) at discharge. 3
• Small hemorrhages restricted to the lower brainstem (pons and medulla) can occasionally have good recovery, particularly when diagnosis is made early. 5

Period of Observation

A period of physiological stabilization and observation is recommended to improve prognostication accuracy. 1 The duration should be determined by clinical judgment, changes in neurological function, degree of support required, and communication with family regarding patient preferences. 1

Rehabilitation

All patients with brainstem hemorrhage should have access to multidisciplinary rehabilitation given the serious nature and complex pattern of evolving disability. 1

Critical Pitfalls to Avoid

• Do not delay intubation in patients with low GCS scores or medullary hemorrhage due to high risk of sudden respiratory arrest. 4, 2, 5
• Do not rely on clinical characteristics alone to distinguish hemorrhage from ischemia—neuroimaging is mandatory. 4, 2
• Avoid hypotension and hypoxia, which worsen secondary brain injury. 4, 2
• Do not use corticosteroids for cerebral edema management as they lack efficacy and increase infection risk. 1
• Do not make premature decisions about withdrawal of support based on initial presentation alone, as prognostication improves significantly after 48-72 hours of stabilization. 1