Intracranial Hemorrhage Treatment & Management

Updated: Oct 13, 2017
  • Author: David S Liebeskind, MD, FAAN, FAHA, FANA; Chief Editor: Helmi L Lutsep, MD  more...
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Treatment

Medical Care

Medical therapy of intracranial hemorrhage is principally focused on adjunctive measures to minimize injury and to stabilize individuals in the perioperative phase.  Clinical trial data had suggested that treatment with recombinant factor VIIa (rFVIIa) within 4 hours after the onset of intracerebral hemorrhage limited the growth of the hematoma, reduced mortality, and improved functional outcomes at 90 days. [10] However, further study of this medication in a broader cohort did not result in improved clinical outcomes. This intervention may also result in a small increase in the frequency of thromboembolic adverse events. The early use of rFVIIa in patients with head injury without systemic coagulopathy may reduce the occurrence of enlargement of contusions, the requirement of further operation, and adverse outcome. [11]

  • Perform endotracheal intubation for patients with decreased level of consciousness and poor airway protection.
  • Cautiously lower blood pressure to a mean arterial pressure (MAP) less than 130 mm Hg, but avoid excessive hypotension. Early treatment in patients presenting with spontaneous intracerebral hemorrhage is important as it may decrease hematoma enlargement and lead to better neurologic outcome. [12]
  • Rapidly stabilize vital signs, and simultaneously acquire emergent CT scan.
  • Intubate and hyperventilate if intracranial pressure is increased; initiate administration of mannitol for further control.
  • Maintain euvolemia, using normotonic rather than hypotonic fluids, to maintain brain perfusion without exacerbating brain edema.
  • Avoid hyperthermia.
  • Correct any identifiable coagulopathy with fresh frozen plasma, vitamin K, protamine, or platelet transfusions.
  • Initiate fosphenytoin or other anticonvulsant definitely for seizure activity or lobar hemorrhage, and optionally in other patients.Levetiracetam has shown efficacy in children for prophylaxis of early posthemorrhagic seizures. [13] Additional data suggest that levetiracetam is more effective than phenytoin for seizure prophylaxis without suppression of cognitive abilities in patients with ICH. [14]
  • Facilitate transfer to the operating room or ICU.
  • While reducing SBP with intravenous nicardipine hydrochloride does not significantly reduce hematoma expansion in patients with ICH, the Antihypertensive Treatment of Acute Cerebral Hemorrhage study supports further studies to evaluate the efficacy of aggressive pharmacologic SBP reduction. [15]
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Surgical Care

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  • Consider nonsurgical management for patients with minimal neurological deficits or with intracerebral hemorrhage volumes less than 10 mL.
  • Consider surgery for patients with cerebellar hemorrhage greater than 3 cm, for patients with intracerebral hemorrhage associated with a structural vascular lesion, and for young patients with lobar hemorrhage. The common hypertensive hemorrhages in the basal ganglia have not been shown clearly to benefit from surgery, although case series with favorable outcomes after stereotactic needle evacuation or endoscopic drainage have been reported. In the past, standard craniotomy with evacuation of the hematoma did not appear to improve outcomes.
  • Other surgical considerations include the following:
    • Clinical course and timing
    • Patient's age and comorbid conditions
    • Etiology
    • Location of the hematoma
    • Mass effect and drainage patterns
  • Surgical approaches include the following:
    • Craniotomy and clot evacuation under direct visual guidance
    • Stereotactic aspiration with thrombolytic agents
    • Endoscopic evacuation
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Consultations

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  • Neurosurgeon
  • Neurologist
  • Interventional neuroradiologist
  • Rehabilitation specialist
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Diet

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  • Employ aspiration precautions and obtain evaluation of patient's swallowing.
  • Initiate enteral feedings as soon as possible. The patient may require placement of a nasogastric tube or percutaneous device.
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Activity

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  • Maintain bedrest during the first 24 hours.
  • Follow with progressive increase in activity.
  • Avoid strenuous exertion.
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