What is the immediate management of an adult with acute intracranial hemorrhage presenting with sudden neurological decline, headache, vomiting, and possible anticoagulant use?

Immediate Management of Acute Intracranial Hemorrhage

Stabilize the airway, breathing, and circulation immediately, obtain emergent non-contrast CT imaging to confirm the diagnosis, reverse any coagulopathy, control blood pressure to systolic 140 mmHg if presenting BP is 150-220 mmHg, admit to a neuroscience intensive care unit, and monitor neurological status frequently with standardized scales while maintaining cerebral perfusion pressure above 60 mmHg. 1, 2, 3

Initial Stabilization and Diagnosis

Airway and Breathing Management:

• Assess airway patency and oxygenation immediately via respiratory status and pulse oximetry 1
• Intubate patients with impaired consciousness (GCS ≤8), those unable to protect their airway, or those with respiratory compromise 1, 2
• Avoid hypoxia and hypercarbia as both exacerbate raised intracranial pressure 4

Immediate Diagnostic Imaging:

• Obtain emergent non-contrast head CT scan, which is the gold standard for identifying acute hemorrhage 2, 3
• CT is mandatory to distinguish ICH from ischemic stroke, as clinical presentation alone is insufficient for reliable differentiation 3
• Earlier imaging from symptom onset increases likelihood of detecting subsequent hematoma expansion (28-38% expand when imaged within 3 hours) 3

Neurological Monitoring

Frequent Neurological Assessment:

• Assess neurological status frequently using standardized stroke scales such as the NIHSS and coma scales such as the GCS 1
• The GCS score and hematoma volume are the most powerful predictors of 30-day mortality 2, 3
• Perform complete NIHSS assessment on admission to intensive care unit, with abbreviated versions for more frequent assessments 1

Critical Care Unit Admission:

• Admit to a neuroscience intensive care unit, as this may result in reduced mortality rates 1
• Maintain nurse-patient ratio of 1:2 for the first 24 hours, then 1:4 if stable 1
• The vast majority of ICH patients require intensive care admission due to impaired consciousness, elevated blood pressure, and frequent need for intubation 1

Blood Pressure Management

Target Blood Pressure:

• For patients with systolic BP between 150-220 mmHg, acutely lower to 140 mmHg, as this is safe and can improve functional outcomes 4
• Intensive BP lowering within 2 hours of ICH onset may be particularly beneficial in reducing hematoma expansion 4
• Achieving lower and more stable BP during the first 24 hours is associated with reduced hematoma growth, less neurological deterioration, and better functional recovery 4

Blood Pressure Monitoring:

• Use automated cuff for adequate monitoring in stable patients 1
• Consider continuous monitoring of systemic arterial pressure in patients requiring continuous intravenous antihypertensive medications and in those whose neurological status is deteriorating 1
• Avoid rapid decline in blood pressure, as this was associated with increased death rate in retrospective studies 1

Cerebral Perfusion Pressure:

• Preserve cerebral perfusion pressure >60 mmHg based on experience in traumatic brain hemorrhage and spontaneous ICH 1
• Avoid cardiopulmonary instability in association with increased ICP to minimize deleterious effects in patients with limited autoregulatory capacity 1

Coagulopathy Reversal

Anticoagulation Reversal:

• Correct INR as rapidly as possible for patients on oral anticoagulants with life-threatening bleeding 2
• Obtain immediate laboratory work including prothrombin time/INR, activated partial thromboplastin time, fibrinogen level, complete blood count with platelets, and type and cross-match 1
• Known coagulopathies should be corrected and oral anticoagulation reversed 5

Hemorrhagic Transformation Management:

• Suspect hemorrhagic transformation if there is change in level of consciousness, elevation of blood pressure, deterioration in motor examination, onset of new headache, or nausea and vomiting 1
• Be prepared to administer 6 to 8 units of cryoprecipitate containing factor VIII and 6 to 8 units of platelets if hemorrhagic transformation occurs 1

Intracranial Pressure Management

ICP Monitoring Indications:

• Consider ICP monitoring in patients with GCS ≤8, those with hydrocephalus, or those with clinical evidence of transtentorial herniation 2
• Fiberoptic ICP monitors within brain parenchyma and ventricular catheters can detect dynamic changes 1
• Hydrocephalus is an independent indicator of 30-day death 3

ICP Management Strategies:

• Elevate head of bed 20-30 degrees to help venous drainage 4
• Avoid hypo-osmolar fluids that may worsen cerebral edema 4
• Treat factors that exacerbate raised intracranial pressure including hypoxia, hypercarbia, and hyperthermia 4

Evidence Limitations:

• There is insufficient evidence from RCTs to make strong recommendations on measures to lower intracranial pressure for adults with acute ICH 1
• Glycerol and mannitol were tested in RCTs with no apparent benefits 1

Surgical Considerations

Cerebellar Hemorrhage:

• Immediate surgical evacuation is recommended for patients with cerebellar hemorrhage who are deteriorating neurologically, have brainstem compression, hydrocephalus, or cerebellar ICH volume ≥15 mL 2
• Hemorrhages >3 cm with neurological deterioration, brainstem compression, or hydrocephalus require urgent surgical evacuation 4

Supratentorial Hemorrhage:

• For lobar hemorrhages within 1 cm of cortical surface in patients with GCS 9-12, surgery may benefit with approximately 29% relative improvement in functional outcomes 4
• Deep hemorrhages (thalamic, basal ganglia) generally have worse outcomes with surgical intervention compared to medical management, especially in patients presenting with coma 4
• Decompressive craniectomy may be considered for patients with high ICP and mass effect 2

Hydrocephalus Management:

• External ventricular drainage through an intraventricular catheter is indicated for acute obstructive hydrocephalus contributing to neurological decline 6
• Allow for slow, controlled release of cerebrospinal fluid after IVC insertion to mitigate effects of increasing transmural pressure gradient 6

Prevention of Secondary Complications

Medical Complications:

• Monitor for and manage pneumonia, cardiac events, and acute kidney injury 2
• Manage fever, as occurrence of fever has been associated with worsened outcome in acute stroke including ICH 1
• Seizures may occur in up to 23% of patients within the first days of stroke and require appropriate management 4

Thromboembolism Prophylaxis:

• Initiate deep venous thrombosis prophylaxis once bleeding has stabilized 2
• Thromboembolic prophylaxis is routine but prophylactic antiepileptic drugs confer no benefit 5

Critical Pitfalls to Avoid

• Do not base surgical decisions solely on hematoma size without considering location, as deep hemorrhages have worse outcomes with surgery regardless of size 4
• Avoid surgery in comatose patients (GCS ≤8), as this population consistently shows worse outcomes with surgical intervention 4
• Do not perform invasive procedures such as arterial punctures or insertion of catheters or nasogastric tubes in the first 24 hours after thrombolytic treatment if applicable 1
• Clinical presentation alone is insufficient to reliably differentiate ICH from other stroke subtypes; neuroimaging is mandatory for definitive diagnosis 3
• Early neurological deterioration is common within the first few hours after ICH onset, necessitating close monitoring 1