What is the recommended initial management for a patient with suspected intracranial hemorrhage?

Initial Management of Suspected Intracranial Hemorrhage

Immediately stabilize the patient with airway, breathing, and circulation (ABCs), obtain urgent non-contrast head CT to confirm the diagnosis, and simultaneously initiate reversal of any anticoagulation while maintaining strict blood pressure control with systolic BP <140 mmHg. 1, 2

Immediate Diagnostic Evaluation

• Obtain non-contrast head CT scan urgently as the gold standard diagnostic tool to confirm intracranial hemorrhage and determine location, size, and presence of mass effect 3, 4, 5
• Perform urgent neurological assessment including pupillary examination and Glasgow Coma Scale motor score (if feasible) to determine severity of brain injury 1
• Consider CT angiography (CTA) plus venography in specific scenarios: lobar hemorrhage in patients <70 years, deep/posterior fossa hemorrhage in patients <45 years, or deep/posterior fossa hemorrhage in patients 45-70 years without hypertension history to exclude macrovascular causes 1

Critical Initial Interventions

Blood Pressure Management

• Target systolic blood pressure <140 mmHg (strictly avoiding SBP <110 mmHg) within the first 6 hours of symptom onset to reduce hematoma expansion risk 1, 2
• Maintain mean arterial pressure >80 mmHg during any emergency interventions 1
• Intensive BP reduction directly reduces hematoma expansion and improves outcomes 2

Immediate Anticoagulation Reversal

For Vitamin K Antagonists (Warfarin):

• Discontinue warfarin immediately when intracranial hemorrhage is confirmed or suspected 1
• If INR ≥1.4: Administer 4-factor prothrombin complex concentrate (PCC) IV (weight-based dosing according to INR and PCC type) PLUS vitamin K 10 mg IV 1
• 4-factor PCC is strongly preferred over fresh frozen plasma (FFP) due to faster onset of action 1
• If PCC unavailable, use FFP 10-15 mL/kg IV with vitamin K 10 mg IV 1
• Repeat INR testing 15-60 minutes after PCC administration, then serially every 6-8 hours for 24-48 hours 1
• If repeat INR remains ≥1.4 within 24-48 hours, redose with vitamin K 10 mg IV 1

For Direct Oral Anticoagulants (DOACs):

• Discontinue DOACs immediately when hemorrhage is confirmed or suspected 1, 2
• For dabigatran: Administer idarucizumab 5 g IV in two divided doses if drug was given within 3-5 half-lives or if renal insufficiency is present 1
• For factor Xa inhibitors (rivaroxaban, apixaban, edoxaban): Administer 4-factor PCC 50 U/kg IV or activated PCC (FEIBA) 50 U/kg IV 1, 2
• Administer activated charcoal 50 g to intubated patients with enteral access who present within 2 hours of oral DOAC ingestion 1
• Reversal decisions should be guided primarily by bleeding severity and dosing history, NOT laboratory testing 1, 6

For Heparin:

• Administer protamine sulfate 1 mg per 100 units of heparin given in the previous 2-3 hours (maximum 50 mg single dose) 1, 2

For Low Molecular Weight Heparin (Enoxaparin):

• For therapeutic-dose enoxaparin given within 8 hours: Administer protamine 1 mg per 1 mg of enoxaparin (maximum 50 mg single dose) 6, 2
• For prophylactic-dose enoxaparin, routine reversal is NOT recommended unless aPTT is significantly prolonged 6
• If life-threatening bleeding persists, consider redosing protamine at 0.5 mg per 100 anti-Xa units 6

For Antiplatelet Agents:

• Stop aspirin, clopidogrel, and dipyridamole/ASA immediately 1
• Do NOT routinely administer platelet transfusions unless neurosurgical intervention is planned 1

Triage and Consultation Decisions

Neurosurgical Consultation

• Obtain urgent neurosurgical consultation for all salvageable patients with life-threatening brain lesions after control of any systemic hemorrhage 1
• Immediate neurosurgical referral for cerebellar hemorrhage with altered consciousness or new brainstem symptoms 1
• Urgent consultation for acute hydrocephalus requiring external ventricular drainage (EVD) 1
• Supratentorial hemorrhage: Surgical evacuation has not proven superior to conservative management in most patients, but consider early intervention in select patients with GCS 9-12 1

Admission Location

• Admit medically stable patients to a stroke unit or neuro-intensive care unit 1, 3
• Critically ill patients require intensive care unit admission 1

Monitoring and Supportive Care

• Institute intracranial pressure (ICP) monitoring for comatose patients with radiological signs of intracranial hypertension, regardless of need for emergency extra-cranial surgery 1
• Cardiac monitoring for at least 24 hours to screen for atrial fibrillation and serious arrhythmias 1
• Maintain cerebral perfusion pressure 50-70 mmHg 2
• Monitor body temperature and treat fever >38°C 1
• Antiseizure medications are indicated ONLY for documented seizures, not prophylactically 1

Critical Pitfalls to Avoid

• Never delay anticoagulation reversal while waiting for laboratory results—base decisions on bleeding severity and medication history 1, 6
• Do not use recombinant Factor VIIa (rFVIIa) for warfarin reversal—it increases arterial thromboembolic events without clinical benefit 1
• Avoid deferring goals of care discussions or DNR decisions for at least 24-48 hours after stroke onset to allow time for response to therapy, unless patient has preexisting wishes 1
• Do not restart anticoagulation before repeat imaging confirms hemorrhage stability—premature resumption dramatically increases mortality and rebleeding risk 6, 2
• Never give therapeutic anticoagulation during active intracranial bleeding 6