What are the immediate assessment, stabilization, and emergent management steps for a patient with suspected intracranial hemorrhage?

Immediate Management of Intracranial Hemorrhage

Treat intracranial hemorrhage as a medical emergency requiring immediate stabilization of airway, breathing, and circulation, followed by emergent non-contrast CT imaging, blood pressure control, coagulopathy reversal, and neurosurgical consultation within the first hour of presentation. 1, 2, 3

Initial Stabilization (First 15 Minutes)

Airway and Breathing

• Intubate immediately if GCS ≤8, altered consciousness, or respiratory failure without delay, as pontine and large hemorrhages commonly cause respiratory dysfunction 2, 3
• Maintain PaO2 between 60-100 mmHg and PaCO2 between 35-40 mmHg to avoid both hypoxemia and hypercapnia, which worsen secondary brain injury 2, 3
• Elevate head of bed to 20-30 degrees with neck in neutral midline position to optimize jugular venous drainage and reduce intracranial pressure 2

Circulation

• Establish large-bore IV access immediately for fluid resuscitation and medication administration 3
• Target systolic blood pressure >100 mmHg or MAP >80 mmHg to maintain cerebral perfusion pressure ≥60 mmHg 2, 4
• Avoid neck rotation or tight cervical collars that obstruct internal jugular vein drainage and worsen intracranial pressure 2

Neurological Assessment (Within 5 Minutes)

• Perform NIHSS on awake/drowsy patients or GCS on obtunded/comatose patients as baseline severity assessment and strong predictor of outcomes 1
• Conduct focused neurological examination including pupil size/reactivity and motor response 3
• Assess for clinical signs of increased intracranial pressure (altered consciousness, pupillary changes, posturing) 1
• Repeat validated neurological scale (CNS score) at least hourly for the first 24 hours depending on patient stability 1

Emergent Neuroimaging (Within 15-30 Minutes)

• Obtain emergent non-contrast CT head immediately to confirm diagnosis, determine hemorrhage location/volume, assess for hydrocephalus or intraventricular extension, and exclude mass effect 1, 2, 4, 3
• Never perform lumbar puncture before neuroimaging, as this can precipitate herniation in the setting of elevated intracranial pressure 2
• Consider CT angiography to exclude underlying vascular lesions (aneurysm, arteriovenous malformation) with sensitivity/specificity exceeding 90% 1, 4
• Repeat imaging at 24 hours to evaluate for hematoma expansion if clinically indicated 4

Blood Pressure Management (Initiate Within 15 Minutes)

For Hemorrhage Without Mass Effect

• Target systolic blood pressure 140-160 mmHg within 6 hours of symptom onset while maintaining MAP <130 mmHg and cerebral perfusion pressure ≥60 mmHg at all times 4
• Never reduce blood pressure by more than 70 mmHg within the first hour—excessive drops cause acute renal injury, early neurological deterioration, increased mortality, and compromised cerebral perfusion 4

For Hemorrhage With Mass Effect or Elevated ICP

• Prioritize maintaining cerebral perfusion pressure ≥60 mmHg (CPP = MAP - ICP) over aggressive systemic blood pressure reduction 4
• Target systolic blood pressure <140 mmHg for safety, though insufficient evidence exists for better clinical outcomes with lower targets 1

Practical Implementation

• Assess blood pressure on initial arrival and every 15 minutes until stabilized 1
• Use labetalol as first-line treatment if no contraindications, as it does not act centrally and avoids confounding neurological examination 1, 2
• Continue close blood pressure monitoring every 30-60 minutes (or more frequently if above target) for at least 24-48 hours 1

Coagulopathy Reversal (Initiate Immediately)

Initial Assessment

• Obtain medication history, platelet count, PTT, and INR immediately 1
• Draw baseline coagulation parameters including fibrinogen and type/cross-match 3

Anticoagulant Reversal

For LMWH (Enoxaparin):

• Administer protamine sulfate 1 mg per 1 mg of enoxaparin (maximum 50 mg single dose) if given within 8 hours 1
• Give 0.5 mg protamine per 1 mg enoxaparin if given within 8-12 hours 1
• Administer by slow IV injection over 10 minutes 1

For Pentasaccharides (Fondaparinux):

• Administer aPCC 20 IU/kg for reversal 1
• If aPCC contraindicated/unavailable, give rFVIIa 90 μg/kg 1

For Thrombolytic-Related ICH:

• Give cryoprecipitate 10 units initial dose if thrombolytic given within 24 hours 1
• If cryoprecipitate unavailable, use tranexamic acid 10-15 mg/kg IV over 20 minutes or ε-aminocaproic acid 4-5 g IV 1
• Check fibrinogen after reversal; if <150 mg/dL, give additional cryoprecipitate 1

Antiplatelet Reversal

• Discontinue antiplatelet agents immediately 1
• Do NOT give platelet transfusion for non-surgical patients regardless of antiplatelet type, hemorrhage volume, or neurologic examination 1
• Give platelet transfusion only if neurosurgical procedure planned for aspirin- or ADP inhibitor-associated ICH 1
• Perform platelet function testing prior to transfusion if possible 1

Intracranial Pressure Management

ICP Monitoring

• Institute ICP monitoring with intraventricular catheter or intraparenchymal probe if GCS ≤8 or radiological signs of intracranial hypertension 2

Elevated ICP Treatment

• Administer osmotic therapy with mannitol (up to 2 g/kg) or hypertonic saline (3%) if signs of herniation or elevated ICP develop 2
• Consider temporary hyperventilation (PaCO2 30-35 mmHg) only for acute herniation while awaiting definitive intervention 2
• Do NOT use corticosteroids—they are ineffective for intracerebral hemorrhage and potentially harmful 2
• Do NOT use hypotonic fluids—they worsen cerebral edema 2

Neurosurgical Consultation (Within 30 Minutes)

• Obtain immediate neurosurgical consultation for all patients with ICH 2, 3
• Surgical intervention may be indicated for obstructive hydrocephalus requiring external ventricular drain placement 2

Ongoing Critical Care Monitoring

• Admit to ICU for continuous monitoring of coagulation parameters, hemoglobin, blood gases, and neurological status 4
• Maintain platelet count >75 × 10⁹/L—levels <50 × 10⁹/L strongly associated with microvascular bleeding 4
• Maintain fibrinogen >1.5 g/L for adequate hemostasis 4
• Monitor blood lactate and base deficit to assess tissue hypoperfusion 3

Critical Pitfalls to Avoid

• Never delay imaging for clinical assessment—CT must be obtained within 15-30 minutes 1, 2
• Never reduce blood pressure precipitously—gradual reduction over hours prevents cerebral hypoperfusion 4
• Never give empiric platelet transfusions to non-surgical patients—this worsens outcomes 1
• Never obstruct jugular venous drainage with neck rotation or tight collars 2
• Never use hypotonic IV fluids or corticosteroids 2