Treatment of Brain Bleed

Initial Assessment and Management

The American Heart Association recommends rapid neuroimaging with CT or MRI to distinguish intracerebral hemorrhage from ischemic stroke, with CT being the gold standard for identifying acute hemorrhage 1, 2
Early deterioration is common in the first few hours after onset, with over 20% of patients experiencing a decrease in Glasgow Coma Scale (GCS) of two or more points between prehospital assessment and emergency department evaluation, according to the American Heart Association 1
Primary objectives in prehospital setting include providing ventilatory and cardiovascular support and transporting the patient to the closest facility prepared to care for acute stroke patients, as recommended by the American Heart Association 3

Aggressive blood pressure management is recommended by the American College of Cardiology to prevent hematoma growth in patients with intracerebral hemorrhage 2
The high rate of early neurologic deterioration is partly related to active bleeding that may proceed for hours after symptom onset, according to the American Heart Association 3
Hematoma expansion is predictive of clinical deterioration and increased morbidity and mortality, as reported by the American Heart Association 3

For patients on oral anticoagulants with life-threatening bleeding, correction of international normalized ratio (INR) should be done as rapidly as possible, according to the American College of Chest Physicians 2
Platelets should be administered to maintain a platelet count above 50×10^9/l in patients with ongoing bleeding and/or traumatic brain injury, as recommended by the Society of Critical Care Medicine 4
Mechanical thromboprophylaxis with intermittent pneumatic compression and/or anti-embolic stockings may be applied as soon as possible, with pharmacological thromboprophylaxis employed within 24 hours after bleeding has been controlled, according to the Society of Critical Care Medicine 4

For most patients with ICH, the usefulness of surgery is uncertain (Class IIb, Level of Evidence C), according to the American Heart Association 5
Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brain stem compression and/or hydrocephalus from ventricular obstruction should undergo surgical evacuation, as recommended by the American Heart Association 5, 2
The STICH trial found that patients with hematomas extending to within 1 cm of the cortical surface had a trend towards more favorable outcome with surgery within 96 hours, according to the American Heart Association 5

Monitoring for and managing medical complications, including pneumonia, cardiac events, and acute kidney injury, as well as fever management and seizure prophylaxis is recommended by the American College of Critical Care Medicine 2
Deep venous thrombosis prophylaxis should be initiated once bleeding has stabilized, according to the American College of Chest Physicians 2
Intracranial pressure (ICP) monitoring should be considered in patients with GCS ≤8, those with hydrocephalus, or those with clinical evidence of transtentorial herniation, as recommended by the American College of Critical Care Medicine 2

The volume of intracerebral hemorrhage and Glasgow Coma Scale score on admission are the most powerful predictors of 30-day mortality, according to the American Heart Association 2
Early aggressive care is warranted as most patients present with small intracerebral hemorrhages that are readily survivable with good medical care, as recommended by the American Heart Association 1, 2