What is the recommended management for a patient with a frontal intracerebral hemorrhage causing a measurable midline shift?

Management of Frontal Intracerebral Hemorrhage with Midline Shift

For a frontal intracerebral hemorrhage causing midline shift, surgical evacuation via craniotomy should be strongly considered, particularly if the hemorrhage is lobar and within 1 cm of the cortical surface, the patient has a Glasgow Coma Scale score of 9-12, or there is neurological deterioration. 1

Immediate Assessment and Stabilization

Neurological Evaluation

• Assess Glasgow Coma Scale score immediately - patients with GCS ≤8 require intubation and are at highest risk for herniation 2, 1
• Document presence and degree of midline shift - shift >5mm combined with hematoma thickness >10mm or neurological deterioration indicates need for surgical evacuation 1
• Evaluate for signs of transtentorial herniation (pupillary changes, posturing, deteriorating consciousness) - these patients require urgent intervention 2

Imaging Requirements

• Obtain CT angiography if available to assess for spot sign (predictor of hematoma expansion) and rule out underlying vascular lesions 2
• Repeat CT at 6 and 24 hours to monitor for hematoma expansion, which occurs in 26% of patients within the first hour and an additional 12% by 20 hours 2

Surgical Decision-Making Algorithm

Strong Indications for Craniotomy

• Lobar frontal hemorrhage within 1 cm of cortical surface - the American Heart Association reports a trend toward improved outcomes (OR 0.69,95% CI 0.47-1.01) 1
• GCS 9-12 with lobar hemorrhage - these patients show trend toward better outcomes with surgery 1
• Progressive neurological deterioration - surgery should be considered as a lifesaving measure with possible mortality benefit 1
• Hematoma volume >15 mL - associated with mortality benefit from surgical intervention 1

Decompressive Craniectomy Considerations

• For patients presenting in coma with large hematomas and significant midline shift, decompressive craniectomy with or without hematoma evacuation may reduce mortality 1, 3
• Refractory elevated intracranial pressure despite medical management warrants decompressive surgery 1

Timing of Surgery

• Intervention within 8 hours of hemorrhage onset may improve outcomes based on meta-analysis data 1
• Avoid ultra-early craniotomy within 4 hours due to increased risk of rebleeding 1, 4
• Urgent surgery is indicated for rapidly deteriorating patients regardless of time window 4

Medical Management Considerations

Blood Pressure Control

• Target systolic BP <160 mmHg while avoiding hypotension (systolic <110 mmHg) 3, 5
• Careful reduction avoiding drops ≥60 mmHg within 1 hour to prevent secondary injury 5

Intracranial Pressure Management

• Consider ICP monitoring for patients with GCS ≤8, clinical evidence of herniation, or significant intraventricular hemorrhage 2
• Maintain cerebral perfusion pressure 60-70 mmHg in the post-operative period 1, 4
• Ventricular drainage is reasonable if hydrocephalus develops 2

Coagulopathy Reversal

• Reverse anticoagulation immediately if patient is on warfarin (use prothrombin complex concentrate), NOACs (idarucizumab for dabigatran, PCC or andexanet alfa for anti-Xa agents), or antiplatelet agents 3, 5

Post-Operative Management

Monitoring Requirements

• ICP monitoring is recommended following surgery for large hematomas, particularly with severe neurological deficits 1, 4
• Maintain normothermia (36-37°C) and blood glucose 6-10 mmol/L 1, 3
• Monitor for complications including rebleeding, hydrocephalus, wound dehiscence, and meningitis 1, 4

Critical Pitfalls to Avoid

• Do not delay neurosurgical consultation for "medical optimization" beyond basic resuscitation in patients with significant midline shift and neurological deterioration 3
• Avoid routine surgery for deep ganglionic hemorrhages - the STICH trials showed no benefit for these locations, only for superficial lobar hemorrhages 2
• Do not use external ventricular drainage alone if there is mass effect requiring decompression 4
• Avoid premature prognostication - early do-not-resuscitate orders within the first 24-48 hours should be used judiciously 5

Special Consideration for Conservative Management

If the patient has a small hematoma (<12 mL) without neurological deterioration, conservative management with close monitoring may be appropriate, as smaller volumes showed lower likelihood of good outcomes with surgical intervention 1. However, the presence of midline shift typically indicates a larger hematoma requiring intervention.