| Clinical manifestations |
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- Unexplained acute or subacute progressive neurologic symptoms
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- New neurologic symptoms in an older patient (especially if taking anticoagulants)
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- Common symptoms: New and persistent headache, focal or bilateral weakness, confusion, subacute cognitive decline, seizures
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- Signs of elevated intracranial pressure:
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- Cushing triad (bradycardia, respiratory depression, hypertension)
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| Evaluation |
- Assess airway, breathing, circulation, and disability to initiate supportive care
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- Determine GCS and neurologic deficits (eg, hemiparesis, numbness, speech or vision impairment)
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- Identify exposure to anticoagulant medications (eg, warfarin, DOACs, heparinoids)
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- Obtain emergency imaging (eg, head CT or fast MRI)
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- Laboratory evaluation: Complete blood count, PT, PTT, INR, basic electrolytes, pregnancy test in female of childbearing age
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- Initial serial monitoring:
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- Neurologic examination (hourly) for signs of deterioration
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- Repeat head CT 6 to 8 hours after initial study and for any clinical signs of deterioration
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| Treatment |
- Manage trauma patients according to principles of advanced trauma life support*
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- Perform tracheal intubation for any patient unable to protect their airway, with rapidly deteriorating mental status, or with GCS ≤8
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- Obtain immediate neurosurgical consultation as indicated by clinical signs or imaging:
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- Hemispheric SDH >10 mm thickness or midline shift >5 mm
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- SDH causing brainstem compression or pupillary abnormalities
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- SDH causing progressive neurologic deterioration (eg, GCS drop ≥2 points)
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- Reverse anticoagulation (agent specific):
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- Warfarin – Reverse with 4-factor PCC and IV vitamin K
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- Dabigatran – Reverse with idarucizumab
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- Factor Xa inhibitors (apixaban, edoxaban, rivaroxaban) – Reverse with 4-factor PCC or andexanet alfa
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- Heparin (unfractionated) – Reverse with protamine sulfate
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- Low molecular weight heparin – Reverse with andexanet alfa; protamine sulfate is an alternative
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- Medical management of intracranial pressure:
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- Prevent HYPOtension to maintain SBP >100 mmHg: fluid resuscitation with isotonic IV fluids; phenylephrine for refractory symptoms – Initial dose 0.5 to 2 mcg/kg per minute IV; maintenance dose 0.25 to 5 mcg/kg per minute
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- Initial treatment to rapidly reduce SBP to <220 mmHg: nicardipine 5 mg/hour IV, titrate by 2.5 mg/hour every 5 to 15 minutes (maximum dose: 15 mg/hour); alternate: labetalol 20 mg IV bolus, may repeat every 10 minutes
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- Subsequent treatment to reduce SBP to <160 mmHg while monitoring for stability of neurologic status
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- Elevate head of bed >30 degrees
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- Give antipyretics for temperature >38 degrees Celsius (eg, acetaminophen [paracetamol] 325 to 650 mg orally or PR every 4 to 6 hours or 650 mg IV every 4 hours)
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- Repeat imaging (eg, head CT) for signs of new or progressive elevated intracranial pressure:
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- Obtain immediate neurosurgical consultation for surgical indications (refer to above)
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- Osmotic therapy (mannitol or hypertonic saline) or hyperventilation as temporary treatment measures¶
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