What is the recommended intensive care unit management for a patient with intracranial hemorrhage (traumatic, subarachnoid, subdural, epidural, or spontaneous intraparenchymal)?

ICU Management of Intracranial Bleeding

All patients with intracranial hemorrhage should be admitted to a specialized stroke unit or neuro-specific ICU with multidisciplinary teams trained in neurological assessment, as this approach reduces mortality and improves functional outcomes. 1

Immediate Care Setting and Transfer Decisions

Facility-Level Triage:

• Transfer immediately to centers with neurosurgical capabilities if the patient has clinical hydrocephalus, intraventricular hemorrhage (IVH), infratentorial location, or larger supratentorial ICH—this reduces mortality. 1
• Patients with moderate to severe spontaneous ICH, IVH, hydrocephalus, or infratentorial hemorrhage should receive care in a neuro-specific ICU rather than a general ICU to improve outcomes and reduce mortality. 1
• Even patients without initial ICU indications benefit from stroke unit care compared to general ward admission. 1

Pre-Transport Stabilization:

• Before any transfer, initiate life-sustaining therapies for patients who lack adequate airway protection, cannot support gas exchange, or have unstable hemodynamics to prevent acute decompensation during transport. 1

Airway and Hemodynamic Management

Airway Protection:

• Secure the airway immediately in patients with Glasgow Coma Scale (GCS) ≤8, decreased level of consciousness, or signs of increased intracranial pressure (ICP) to prevent aspiration and ensure adequate oxygenation. 2

Blood Pressure Targets:

• Maintain cerebral perfusion pressure (CPP) of 60-70 mmHg, which typically requires mean arterial pressure (MAP) ≥65 mmHg. 3
• The CPP calculation (CPP = MAP - ICP) means blood pressure targets depend on ICP status—if ICP monitoring shows elevated pressures, higher MAP may be needed to maintain adequate CPP. 3
• Avoid CPP >90 mmHg, as this worsens neurological outcomes by potentially aggravating vasogenic cerebral edema. 3
• Measure MAP at the level of the external ear tragus when using invasive monitoring. 3

Intracranial Pressure Monitoring and Management

ICP Monitoring Indications:

• Consider ICP monitoring in patients with GCS ≤8, clinical evidence of transtentorial herniation, or significant IVH/hydrocephalus. 1
• ICP monitoring is strongly indicated after hematoma evacuation in patients with preoperative altered consciousness and focal deficits. 2

Osmotic Therapy with Mannitol:

• Administer mannitol 0.25-0.5 g/kg IV over 20 minutes for threatened intracranial hypertension or signs of brain herniation, repeating every 6 hours as needed with a maximum daily dose of 2 g/kg. 4
• For acute intracranial hypertensive crisis with imminent herniation (decerebrate posturing, Cushing's triad), use 0.5-1 g/kg IV over 15 minutes. 4
• Discontinue mannitol when serum osmolality exceeds 320 mOsm/L to prevent renal failure. 4
• Monitor serum osmolality and electrolytes every 6 hours during active therapy. 4
• Place a urinary catheter before mannitol administration due to profound osmotic diuresis. 4
• Avoid hypoosmolar IV fluids (such as 5% dextrose in water) during mannitol therapy, as these exacerbate cerebral edema. 4
• Hypertonic saline is an alternative when mannitol is contraindicated, particularly when hypovolemia or hypotension is a concern. 4

Adjunctive ICP Management:

• Elevate head of bed to 20-30 degrees with head in neutral position to promote venous drainage. 4
• Use controlled hyperventilation, sedation/analgesia, cerebrospinal fluid drainage via ventriculostomy, barbiturate therapy for refractory ICP, and neuromuscular blockade as needed alongside osmotic therapy. 4

Neuroimaging Protocol

Initial and Serial Imaging:

• Obtain baseline non-contrast head CT immediately upon presentation—this is the standard diagnostic tool. 1, 5
• Perform repeat CT at approximately 6 hours and 24 hours after onset to detect hematoma expansion (HE), which occurs in 26% of patients within the first hour and an additional 12% by 20 hours. 1
• HE is most frequent when initial CT is obtained within 3 hours of onset and progressively declines thereafter (15% between 6-12 hours, 6% between 12-24 hours, extremely rare after 24 hours). 1
• Beyond 24 hours, serial imaging is guided by clinical deterioration rather than routine scheduling. 1

CTA Considerations:

• CTA with spot sign can predict HE and mortality, though sensitivity and positive predictive value are highest between 0-2 hours from onset and decrease over time. 1
• CTA also detects structural causes of secondary ICH. 1

Reversal of Antithrombotic Agents

General Principles:

• Reversal of antithrombotics in intracranial hemorrhage requires prioritizing interventions based on the specific agent, with strength of recommendations accounting for quality of evidence, potential harm, and cost. 1
• These guidelines apply to adult patients with all types of intracranial hemorrhage including subarachnoid, intraparenchymal, intraventricular, subdural, epidural, or traumatic contusion. 1

Antiplatelet Reversal:

• The effect of platelet transfusions for aspirin reversal before craniotomy showed potential benefit in one Chinese population, but requires confirmation in other populations with rigorous data. 1
• Ticagrelor is not reversed by platelet transfusions; a monoclonal antibody antidote is under investigation in phase III trials. 1
• Desmopressin effect remains uncertain due to lack of RCTs, though trials are ongoing. 1

Venous Thromboembolism Prophylaxis

Timing of Pharmacological Prophylaxis:

• Initiate low molecular weight heparin (LMWH) prophylaxis within 24-48 hours after ICH onset once hemorrhage stability is documented on repeat CT. 1
• Studies showing safety used start times of 25 hours (earliest), median 42 hours, or within 48 hours from admission. 1
• Document hemorrhage stability on CT if starting LMWH in the 24-48 hour window. 1

Mechanical Prophylaxis:

• Intermittent pneumatic compression (IPC) devices are more effective than graduated compression stockings for reducing VTE. 1
• Thigh-length compression stockings are more effective than knee-length stockings but primarily reduce asymptomatic proximal DVT. 1

Treatment of Established VTE:

• VTE occurs in 3% of spontaneous ICH patients and is independently associated with poor functional outcomes (mRS ≥4). 1
• Timing of anticoagulation for VTE treatment depends on hematoma size, patient age, and extent of VTE—consider factors such as whether hematoma is progressing before initiating treatment. 1

Multidisciplinary Team Composition

Essential Team Members:

• Care delivery must include multidisciplinary teams with expertise in neurological assessment, including vascular neurology, vascular neurosurgery, critical care, and rehabilitation medicine. 1, 5
• Specialized stroke units with multidisciplinary teams are recommended over general ward care to improve outcomes and reduce mortality. 1

Common Pitfalls to Avoid

• Do not administer mannitol to hypotensive patients with active hemorrhage—bleeding must be controlled first. 4
• Avoid aggressive antihypertensive agents with venodilating properties (e.g., hydralazine) in patients with elevated ICP, as cerebral venodilation further increases ICP. 4
• Do not treat bradycardia in Cushing's triad with atropine or beta-blockers—the bradycardia reflects brainstem compression, not primary cardiac pathology. 4
• Avoid abrupt discontinuation of mannitol after prolonged use—taper gradually by extending dosing intervals to prevent rebound intracranial hypertension. 4
• Graduated compression stockings alone are less effective than pharmacological prophylaxis for reducing pulmonary embolism. 1