From the Guidelines
The treatment of intracranial hemorrhage should prioritize blood pressure control, reversal of anticoagulants, and supportive care, with neurosurgical intervention considered for large hemorrhages causing significant mass effect, as evidenced by the most recent guidelines 1, 2, 3, 4, 5. The management of intracranial hemorrhage (ICH) is complex and depends on the type, location, and severity of the bleeding. Initial management focuses on stabilizing the patient by maintaining adequate oxygenation, controlling blood pressure, and preventing secondary brain injury.
- Key considerations include:
- Blood pressure control: targets typically below 140/90 mmHg for most hemorrhages, using medications like labetalol, nicardipine, or clevidipine administered intravenously 2.
- Reversal of anticoagulants: using specific agents such as vitamin K and fresh frozen plasma or prothrombin complex concentrate for warfarin, protamine for heparin, and specific reversal agents like idarucizumab for dabigatran or andexanet alfa for factor Xa inhibitors 3.
- Supportive care: includes seizure prophylaxis with levetiracetam (500-1000 mg twice daily), maintaining normothermia, controlling intracranial pressure with mannitol (0.25-1 g/kg IV) or hypertonic saline (3% solution), and preventing complications like deep vein thrombosis with pneumatic compression devices 4.
- Neurosurgical intervention may be necessary for large hemorrhages causing significant mass effect, with options including:
- Craniotomy for hematoma evacuation: may be beneficial for patients with lobar clots within 1 cm of the surface and mild deficits (GCS score 9) 5.
- External ventricular drain placement for hydrocephalus: may be necessary for patients with cerebellar hemorrhage and brain stem compression or hydrocephalus 5.
- Decompressive craniectomy for severe swelling: may be considered for patients with severe swelling and increased intracranial pressure 4. The most recent guidelines suggest that surgery does not appear to be helpful in treating most supratentorial ICH and is probably harmful in those patients presenting in coma, but may be helpful in treating those lobar clots within 1 cm of the surface that present in patients with milder deficits (GCS score 9) 5.
From the FDA Drug Label
Reduction of intracranial pressure and brain mass. Adults: 0. 25 to 2 g/kg body weight as a 15% to 25% solution administered over a period of 30 to 60 minutes Pediatric patients: 1 to 2 g/kg body weight or 30 to 60 g/m2 body surface area over a period of 30 to 60 minutes Active intracranial bleeding except during craniotomy
Mannitol (IV) is indicated for the reduction of intracranial pressure and brain mass. The recommended dosage for adults is 0.25 to 2 g/kg body weight, and for pediatric patients, it is 1 to 2 g/kg body weight or 30 to 60 g/m2 body surface area, administered over 30 to 60 minutes. However, it is contraindicated in cases of active intracranial bleeding, except during craniotomy 6.
From the Research
Treatment Options for Intracranial Hemorrhage
- Intracranial hemorrhages are a significant cause of acute neurologic disease, and prompt recognition and treatment are crucial to optimize outcomes 7.
- The use of hyperosmolar agents, such as mannitol or hypertonic saline (HTS), is a common approach to control high intracranial pressure (ICP) in patients with traumatic brain injury or aneurysmal subarachnoid hemorrhage 8, 9, 10, 11.
Hyperosmolar Agents for ICP Reduction
- Studies have shown that HTS can decrease ICP in patients with aneurysmal subarachnoid hemorrhage, with a mean decrease of 8.9 mm Hg 8.
- HTS has been found to be as effective as mannitol in reducing ICP in patients with intracerebral hemorrhage, with some studies suggesting a longer duration of action for HTS 9, 10.
- A systematic review and meta-analysis found that HTS and mannitol had similar effects in reducing ICP, but HTS was associated with a longer duration of effect and shorter ICU stay 10.
Comparison of Mannitol and Hypertonic Saline
- Several studies have compared the effects of mannitol and HTS in patients with elevated ICP, with mixed results 8, 9, 10, 11.
- While some studies suggest that HTS may be more effective than mannitol in reducing ICP, others have found no significant difference between the two agents 8, 10, 11.
- A review article noted that there is insufficient evidence to support a formal recommendation on the use of any specific hyperosmolar medication in patients with acute increased ICP 11.