Treatment of Pontine and Midbrain Hemorrhage

Initial Assessment and Management

The American Heart Association recommends rapid neuroimaging with CT or MRI to diagnose pontine and midbrain hemorrhage, with CT being the gold standard for identifying acute hemorrhage 2
Early deterioration is common in the first 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 Stroke Association 1
Primary objectives in the 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 1

Aggressive blood pressure management is recommended to prevent hematoma expansion in patients with intracerebral hemorrhage, according to the American College of Cardiology 2
For patients with spontaneous intracerebral hemorrhage who present within 6 hours of symptom onset with systolic blood pressure >150 mmHg, blood pressure should be reduced if immediate surgery is not planned, as recommended by the American Society of Anesthesiologists 3
The American Heart Association recommends maintaining systolic blood pressure <160 mmHg for patients with unsecured aneurysms, while avoiding hypotension (systolic <110 mmHg) 3

For patients with evidence of increased ICP, the American Heart Association recommends elevation of the head of the bed to 30 degrees 4
The American Society of Anesthesiologists recommends avoiding hypotonic fluids and using 0.9% saline as the crystalloid solution in brain injury 3

The Society of Critical Care Medicine recommends immediate reversal of anticoagulation in patients on anticoagulants with intracranial hemorrhage 5
For vitamin K antagonists (warfarin), the Society of Critical Care Medicine recommends administering four-factor prothrombin complex concentrate (PCC) and vitamin K 5
For direct thrombin inhibitors (dabigatran), the Society of Critical Care Medicine recommends administering idarucizumab; if unavailable, consider hemodialysis 5
For factor Xa inhibitors, the Society of Critical Care Medicine recommends administering four-factor PCC (50 U/kg) or activated PCC (50 U/kg) 5
For heparin-associated bleeding, the Society of Critical Care Medicine recommends administering protamine sulfate at 1 mg for every 100 units of heparin given in the previous 2-3 hours (maximum single dose 50 mg) 5

The American Heart Association recommends considering surgical evacuation for patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus from ventricular obstruction 6, 2

The American College of Cardiology recommends deep venous thrombosis prophylaxis with intermittent pneumatic compression once bleeding has stabilized 2
The American Heart Association recommends monitoring for and managing medical complications, including pneumonia, cardiac events, and acute kidney injury 2

The American Heart Association recommends intensive care unit admission for close monitoring of vital signs and neurological status 1