How should an acute intracranial hemorrhage presenting with a seizure be managed?

Management of Acute Intracranial Hemorrhage Presenting with Seizure

Treat the seizure immediately with antiseizure medication (preferably levetiracetam), but do NOT continue prophylactic antiseizure drugs beyond 7 days unless seizures recur—the priority is aggressive blood pressure control, reversal of coagulopathy, and neurosurgical consultation for potential hematoma evacuation or ventricular drainage. 1, 2

Immediate Emergency Management

Airway, Breathing, and Circulation

• Ensure adequate ventilation and oxygenation with pulse oximetry monitoring; intubate if GCS ≤8 or if airway protection is compromised 3
• Establish continuous blood pressure monitoring if the patient requires IV antihypertensives or is neurologically deteriorating 3
• Transport immediately to a facility with neurosurgery, neurology, neuroradiology, and neurocritical care capabilities—prehospital notification shortens time to CT scanning 3

Critical Initial Assessment

• Obtain focused history: exact time of symptom onset (or last known normal), medication use (especially anticoagulants/antiplatelets), prior seizure history, and drug/alcohol use 3
• Perform rapid neurological examination using GCS and NIHSS scales—15% of patients deteriorate by ≥2 GCS points within the first hour 3
• Recognize that early neurological decline predicts mortality >75% when GCS drops by an average of 6 points 3

Immediate Neuroimaging

Imaging Modality Selection

• Obtain non-contrast head CT immediately—this is the gold standard for detecting acute hemorrhage and is mandatory since clinical features alone cannot differentiate hemorrhage from ischemia 3, 4
• Consider CT angiography (CTA) if imaging occurs within 3 hours of onset, as 28-38% of patients show hematoma expansion and CTA can identify contrast extravasation predicting further bleeding 3
• MRI with gradient echo sequences is equally sensitive but time, cost, and patient tolerance usually favor CT in the acute setting 3

Seizure Management Algorithm

For Witnessed Clinical Seizures at Presentation

• Administer levetiracetam immediately for any witnessed convulsive seizure—this is a Class I recommendation 3, 1
• Strongly prefer levetiracetam over phenytoin due to better tolerability, fewer drug interactions, no need for serum level monitoring, and most importantly, phenytoin is associated with excess morbidity, mortality, and worse cognitive outcomes at 3 months 1, 2, 4
• Limit antiseizure medication to ≤7 days in the perioperative period unless seizures recur—prophylaxis beyond 7 days does not prevent late seizures and may worsen functional outcomes 1, 2, 4

For Patients Without Witnessed Seizures

• Do NOT routinely administer prophylactic antiseizure medications—the 2022 AHA/ASA guidelines and European Stroke Organisation both state that prophylactic drugs do not prevent seizures and may be associated with worse functional outcomes 3, 1
• Consider continuous EEG monitoring for 24-48 hours if the patient has fluctuating consciousness out of proportion to imaging findings, as 28% of electrographic seizures are detected after 24 hours and 94% by 48 hours 1
• Among comatose ICH patients, 36% require monitoring beyond 24 hours to detect the first seizure 1

High-Risk Features Warranting EEG Monitoring

• Depressed mental status disproportionate to hemorrhage size on imaging 1, 4
• Lobar (cortical) hemorrhage location—these patients have higher seizure risk than deep hemorrhages 3, 5, 6
• Intraventricular extension of hemorrhage 6
• Large hemorrhage volume 6

Treatment of Documented Electrographic Seizures

• Initiate levetiracetam only if EEG documents seizures that are suspected to contribute to impaired consciousness 1
• Nonconvulsive seizures occur in approximately 20% of ICH patients and are associated with poor outcomes 5, 6

Blood Pressure Management

Target Blood Pressure Goals

• For patients presenting within 6 hours of onset with SBP 150-220 mmHg: rapidly lower SBP to <140 mmHg within 1 hour—the 2014 European guidelines indicate this is safe and may be superior to targeting <180 mmHg 3
• Maintain cerebral perfusion pressure (CPP) >60-70 mmHg throughout treatment 3
• Avoid rapid blood pressure decline as one retrospective study associated this with increased mortality 3

Monitoring Requirements

• Use continuous arterial line monitoring if administering IV antihypertensives 3
• Consider ICP monitoring in patients with GCS ≤8, significant mass effect, or hydrocephalus to calculate CPP 3

Coagulopathy Reversal

For Anticoagulated Patients

• Reverse anticoagulation immediately though specific protocols depend on the agent used 3
• The 2014 European guidelines acknowledge insufficient RCT evidence to make strong recommendations about timing and method, but reversal is standard practice 3
• Do NOT routinely use recombinant Factor VIIa (rFVIIa) outside clinical trials—it reduces hematoma expansion but does not improve outcomes and increases thromboembolic complications 3, 7

For Antiplatelet Therapy

• Do NOT routinely transfuse platelets in patients taking aspirin or clopidogrel—there is no evidence this improves outcomes 3, 7

Intracranial Pressure Management

Stepwise ICP Control Strategy

• Begin with simple measures: elevate head of bed to 30 degrees, provide adequate analgesia and sedation 3
• Progress to osmotic therapy (mannitol or hypertonic saline) if ICP remains elevated 3
• Consider external ventricular drainage (EVD) for hydrocephalus or IVH, though the 2014 European guidelines note insufficient RCT evidence for strong recommendations 3
• Use neuromuscular blockade and hyperventilation as temporizing measures while maintaining CPP >70 mmHg 3

Neurosurgical Consultation

Indications for Urgent Neurosurgical Evaluation

• Cerebellar hemorrhage with obstructive hydrocephalus—this is a neurosurgical emergency requiring immediate ventriculostomy and/or suboccipital decompressive craniectomy 1
• Supratentorial ICH with GCS 9-12—early surgery may provide benefit in this specific population 3
• Hydrocephalus from intraventricular hemorrhage requiring EVD placement 3
• Routine surgical evacuation of supratentorial ICH does not improve outcomes compared to medical management, though minimally invasive techniques are under investigation 3, 8

Critical Care Unit Management

Monitoring and Supportive Care

• Admit all ICH patients to a neuroscience intensive care unit—this reduces mortality compared to general ward care 3
• Perform frequent neurological assessments using standardized scales (GCS, NIHSS) to detect early deterioration 3
• Treat fever aggressively to normothermia—fever duration correlates with worse outcomes and increased ICP 3
• **Target glucose <140-185 mg/dL**—persistent hyperglycemia >140 mg/dL in the first 24 hours is associated with poor outcomes 3

Venous Thromboembolism Prophylaxis

• Use intermittent pneumatic compression (IPC) devices—the 2014 European guidelines strongly recommend IPC to reduce DVT risk and improve outcomes 3
• Do NOT use graduated compression stockings alone—these are not recommended 3
• Timing of pharmacologic anticoagulation for VTE prophylaxis remains controversial with insufficient evidence 3

Common Pitfalls to Avoid

Seizure Management Errors

• Do not continue prophylactic antiseizure drugs beyond 7 days based on risk scores—there is no evidence they prevent late seizures 1
• Do not use phenytoin—it is associated with worse outcomes in hemorrhagic stroke 1, 2, 4
• Do not delay neurosurgical consultation while focusing on seizure prophylaxis, especially in cerebellar hemorrhage with hydrocephalus 1

Blood Pressure Management Errors

• Do not lower blood pressure too rapidly—this may compromise cerebral perfusion 3
• Do not ignore CPP—maintain >60-70 mmHg even while lowering systemic blood pressure 3

General Management Errors

• Do not assume early seizures independently worsen outcomes—prospective studies show they are not independently associated with worse neurological outcomes or mortality when other factors are controlled 1
• Do not delay CT imaging—hematoma expansion occurs in 28-38% of patients imaged within 3 hours and is the primary driver of early deterioration 3
• Do not use corticosteroids (dexamethasone)—the 2014 European guidelines recommend against their use outside clinical trials 3