How should a deep basal‑ganglia (gangliocapsular) intracerebral hemorrhage be managed acutely and subacutely?

Management of Gangliocapsular (Basal Ganglia) Intracerebral Hemorrhage

For gangliocapsular hemorrhage, medical management is superior to surgical evacuation in most cases, with surgery reserved only as a life-saving measure in deteriorating patients. 1, 2

Acute Medical Management (First 24 Hours)

Blood Pressure Control

• Achieve intensive blood pressure lowering to systolic 130-140 mmHg within 1 hour for patients presenting within 6 hours with SBP 150-220 mmHg and no immediate surgery planned 1
• Use small boluses of labetalol as first-line agent, with increased sedation as needed 1
• Avoid hypotension (systolic <110 mmHg or MAP <80 mmHg) as this worsens secondary cerebral injury and adversely affects neurological outcomes 1
• This narrow 6-hour therapeutic window is critical—delaying blood pressure lowering beyond this timeframe reduces effectiveness 1

Reversal of Coagulopathy

• Administer prothrombin complex concentrate (PCC) plus intravenous vitamin K immediately for patients on warfarin with elevated INR 1
• Do not use fresh frozen plasma (FFP) for warfarin reversal—PCC is superior as it rapidly reverses coagulopathy while limiting fluid volumes 1
• Give platelet transfusion for severe thrombocytopenia 1
• Provide appropriate factor replacement for severe coagulation factor deficiency 1

Fluid Management

• Use 0.9% normal saline exclusively as the crystalloid of choice to prevent worsening cerebral edema 1
• Avoid hypotonic solutions including Ringer's lactate, Ringer's acetate, and gelatins—these increase brain water content 1
• Do not use albumin or synthetic colloids in early management 1
• Maintain euvolemia through cautious use of isotonic fluids while preventing volume overload 1

Intracranial Pressure Management

• Elevate head of bed 20-30 degrees to facilitate venous drainage 3, 2
• Begin with simple measures: analgesia, sedation, and head elevation 3
• For elevated ICP, use osmotic diuretics (mannitol or hypertonic saline), CSF drainage via ventricular catheter, neuromuscular blockade, and hyperventilation with goal to maintain cerebral perfusion pressure >70 mmHg 3
• These aggressive therapies require concomitant ICP and blood pressure monitoring 3

Glucose Management

• Monitor glucose levels closely and treat hyperglycemia >140 mg/dL, with insulin administration for levels >185 mg/dL 3, 1
• Avoid both hyperglycemia and hypoglycemia 1

Seizure Management

• Treat clinical seizures immediately with antiseizure drugs 1
• Perform EEG for patients with altered mental status and treat electrographic seizures 1
• Do not use prophylactic antiseizure drugs routinely unless seizures are documented 1
• A brief period of prophylactic therapy may be considered for lobar hemorrhage only 3

Surgical Decision-Making Algorithm

Step 1: Assess Hemorrhage Location and Size

• Deep basal ganglia hemorrhages generally have worse outcomes with surgical intervention compared to medical management 1, 2
• The STICH trial demonstrated that minimally invasive approaches for deep hemorrhages had an odds ratio of 1.3 for poor outcomes compared to medical management 3

Step 2: Evaluate Clinical Status

• Surgery is contraindicated in comatose patients (GCS ≤8) as this population consistently shows worse outcomes with surgical intervention 2
• Patients with GCS 9-12 may be considered for surgery only if the hemorrhage is lobar and within 1 cm of cortical surface—not applicable to gangliocapsular bleeds 2, 4

Step 3: Identify Life-Threatening Indications

Surgery should be considered only as a life-saving measure in the following scenarios: 1, 4

• Neurologically deteriorating patients despite maximal medical management
• Comatose patients with large hematomas causing significant midline shift (>5 mm) combined with hematoma thickness >10 mm 4
• Refractory elevated ICP despite medical management 1, 4

Step 4: Surgical Timing Considerations

• Avoid ultra-early craniotomy within 4 hours due to increased rebleeding risk 1, 4
• For minimally invasive surgery, the optimal window is 6-12 hours after onset for hematomas 30-50 mL 5
• For larger hematomas (>50 mL), ultra-early minimally invasive intervention (≤6 hours) may achieve better results 5

Step 5: Surgical Technique Selection

• Decompressive craniectomy with or without hematoma evacuation may reduce mortality in comatose patients with large hematomas, significant midline shift, or elevated ICP refractory to medical management 3, 1, 4
• Minimally invasive techniques (endoscopic surgery or stereotactic aspiration with thrombolytics) show promise but remain investigational 3, 6
• Endoscopic surgery may be safer and more effective than craniotomy or simple aspiration for moderate basal ganglia hemorrhages, with better neurologic outcomes 7
• Conventional craniotomy for deep ganglionic hemorrhages showed no mortality or functional benefit in randomized trials 4

Management of Intraventricular Extension

• Place external ventricular drainage (EVD) for hydrocephalus if intraventricular hemorrhage is present 1, 4
• Intraventricular thrombolysis remains investigational and should only be used in clinical trials 1
• Attempting to control ICP via ventricular catheter insertion alone without hematoma evacuation is insufficient and may be harmful 3

Subacute Management (Days 2-7)

DVT Prophylaxis

• Begin intermittent pneumatic compression on day of hospital admission 1
• Avoid graduated compression stockings in acute ICH 1
• Consider low-molecular-weight heparin or unfractionated heparin after 48-72 hours if bleeding has stabilized, though evidence is limited for ICH patients 3

Aspiration Prevention

• Perform formal dysphagia screening before initiating any oral intake to reduce pneumonia risk 1

Monitoring and Supportive Care

• Admit to intensive care unit or dedicated stroke unit with neuroscience expertise 1
• Continuous monitoring of blood pressure, neurological status, and vital signs 1
• Repeat non-contrast CT at 6 hours and 24 hours to assess for hematoma expansion 4

Critical Pitfalls to Avoid

• Do not institute DNR orders or withdraw support in the first 48 hours—early prognostication is unreliable and creates self-fulfilling prophecies 1
• Do not use FFP for warfarin reversal; use PCC to limit fluid volumes 1
• Do not use hypotonic crystalloids like Ringer's lactate; use only 0.9% saline 1
• Do not perform ultra-early surgery (within 4 hours) due to increased rebleeding risk 1, 4
• Do not delay blood pressure lowering beyond 6 hours of symptom onset 1
• Do not base surgical decisions solely on hematoma size without considering location—deep hemorrhages have worse outcomes with surgery regardless of size 2
• Do not equate mortality reduction with functional improvement when considering surgery 2

Prognostication Guidance

• Postpone DNR orders until at least the second full day of hospitalization unless pre-existing advance directives exist 1
• Provide aggressive guideline-concordant therapy for all patients without advance directives specifying otherwise 1
• Current prognostication methods are biased by failure to account for withdrawal of support and early DNR orders 1