ED Management of Intracranial Hemorrhage

Robust and comprehensive studies now support specific management guidelines for patients presenting with different intracranial hemorrhages (ICH). From the Emergency Department perspective, the primary dilemmas involve specific blood pressure goals and whether seizure prophylaxis with phenytoin is necessary. The Brain Trauma Foundation provides an excellent summary of the current guidelines.

Summary on the Management of Intracranial Hemorrhages

Primary ICH

Systolic BP Goal (mmHg): < 140-180

Seizure Prophylaxis: No

Therapy:

• External ventricular drain (EVD) if Glasgow Coma Scale (GCS) < 9, significant intraventricular hemorrhage with obstructive hydrocephalus, or herniation
• no platelets

Subdural ICH

Systolic BP Goal (mmHg): Age-dependent blood pressure goal: SBP ≥ 100 mmHg (age 50-69 years) and SBP ≥ 110 mmHg (age >70 years)

Seizure Prophylaxis: Phenytoin if GCS ≤ 10.

Therapy: Surgery if

• Width > 10 mm
• Midline shift > 5 mm
• GCS < 9 or GCS change ≥ 2

Epidural ICH

Systolic BP Goal (mmHg): Age-dependent blood pressure goal: SBP ≥ 100 mmHg (age 50-69 years) and SBP ≥ 110 mmHg (age >70 years)

Seizure Prophylaxis: Phenytoin if GCS ≤ 10.

Therapy: Surgery if

• Volume > 30 mL
• GCS < 9 with asymmetric pupils

Traumatic Subarachnoid Hemorrhage (SAH)

Systolic BP Goal (mmHg): Age-dependent blood pressure goal: SBP ≥ 100 mmHg (age 50-69 years) and SBP ≥ 110 mmHg (age > 70 years)

Seizure Prophylaxis: Phenytoin if GCS ≤ 10.

Therapy: Supportive management

Spontaneous SAH

Systolic BP Goal (mmHg): < 140-160

Seizure Prophylaxis: No

Therapy:

• Early clipping vs coiling
• Transfer to high-volume SAH center

Primary Intracranial Hemorrhages

Primary ICHs include both intraventricular and intraparenchymal bleeds. The majority are due to severe hypertension and are localized to the cerebellum, brainstem, and midbrain. Other etiologies include aneurysm and tumor. Up to 30% of these cases expand within the first 3 hours of onset, which is why treatment guidelines include a systolic blood pressure (SBP) goal of < 140-180 mmHg. This is often achieved with an IV infusion of a vasodilator, such as nicardipine or nitroprusside. In patients with primary ICH, seizure prophylaxis and platelet transfusion may lead to worse outcomes. Indications for an external ventricular drain (EVD) include any of the following:

• Confirmed ICH with a GCS < 9
• Transtentorial herniation
• Significant intraventricular hemorrhage with hydrocephalus

Traumatic Brain Injury including Epidural, Subdural, and Subarachnoid Hemorrhages

In contrast to primary ICHs, phenytoin has been shown to be of benefit for acute traumatic brain injury (TBI). It decreases the incidence of early (≤ 7 days) post-traumatic seizures. Phenytoin is the preferred agent for a patient with a traumatic ICH and a GCS ≤ 10. However, if a patient meets any of the below criteria for seizure prophylaxis but the GCS > 10, then either phenytoin or levetiracetam is acceptable.

Indications for seizure prophylaxis in traumatic ICH 8–13

• GCS ≤ 10 (phenytoin is the agent of choice)
• Depressed skull fracture
• Subdural or epidural hematoma
• Hemorrhagic contusion
• Penetrating head trauma
• Seizure within the first 24 hours

Blood pressure goals in traumatic ICH

• Age 50-69 years: SBP ≥ 100 mmHg
• Age > 70 years: SBP ≥ 110 mmHg

Surgical intervention for subdural hemorrhages

• Width > 10 mm
• Midline shift > 5 mm
• GCS < 9 or GCS change ≥ 2 since injury

Surgical intervention for epidural hemorrhages

• Hemorrhage volume > 30 cm3
• GCS < 9 with asymmetric pupils

Spontaneous Subarachnoid Hemorrhage (SAH)

Spontaneous, atraumatic SAHs have a 5-10% chance of rebleeding in the first 72 hours. Most are due to a ruptured aneurysm and have a SBP goal < 140-160 mmHg until the aneurysm is secured. These hemorrhages should not receive seizure prophylaxis as no benefit has been shown. Early clipping or coiling of the aneurysm is imperative to survival and may require transfer to a high-volume SAH center.

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