Four Neurological Injuries Explained

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When I first started in the ICU I was overwhelmed with all the different neuro diagnoses and how the treatments varied based on where the injury is located, what caused it, and whether or not the patient has had surgery yet. 

In this lesson, you’ll get a high-level overview of four key types of neurological injury: ischemic stroke, subarachnoid hemorrhage, intracerebral hemorrhage, and hematoma. For each condition, we’ll review a basic summary, diagnostic tests, medical treatments, and surgical/invasive treatments.

Ischemic stroke

The most common type of stroke is an ischemic stroke, which occurs when blood flow to the brain tissue is blocked by blood or plaque. As a result of this blockage, brain tissue does not receive oxygen or nutrients and ischemia and cell death occur. Ischemic strokes are generally considered to be preventable in most cases with the greatest risk factors being hypertension, hyperlipidemia, heart disease, and diabetes.

Ischemic stroke diagnostics

• Noncontrast head CT – This CT scan is done as soon as possible after onset of symptoms to rule out the presence of blood in the cerebral tissue. If there is no blood present, the CT scan is considered “negative” and the patient is then evaluated further regarding medical treatment.
• CTA – CT angiography is utilized to confirm a large vessel occlusion in patients who may benefit from a thrombectomy. Many times CT with CTA of the head and neck is conducted and is considered the standard of care in many facilities for patients with onset of symptoms < 4.5 hours.
• MRA – Magnetic resonance angiography looks at the blood vessels of the brain and can show which vessel or vessels is blocked. It can also be utilized to confirm a large vessel occlusion in patients who may benefit from a thrombectomy.
• MRI – Magnetic resonance imaging can also be utilized to evaluate a patient with stroke symptoms, but note this takes much longer than a CT scan. However, an MRI provides much more detailed imaging and can help pinpoint the exact location of damage. You are most likely to see MRI utilized in patients who present with stroke symptoms outside the 6-hour treatment window or in patients who have an uncertain diagnosis of acute stroke.

Medical treatment of ischemic stroke

Treatment for ischemic stroke varies based on the duration of symptoms. 

• Intravenous thrombolysis – For patients who present within the appropriate time frame (generally < 4.5 hours), the mainstay of treatment is thrombolytic therapy using TPA (Alteplase). However, note that not all patients will be candidates for TPA. Examples of exclusion criteria are hemorrhagic stroke, persistent hypertension, and active bleeding of any kind.
• Blood pressure management – Blood pressure must be controlled to reduce the risk of bleeding before thrombolytic therapy can be utilized and for the first 24 hours after administration (goal below 180/105). Patients who do not receive TPA should not have hypertension treated unless it is significant (SBP over 220 mmHg or DBP over 120 mmHg) or in cases of certain medical conditions such as ischemic coronary artery disease, heart failure or aortic dissection.
• Anticoagulation – Patients with acute stroke are at high risk for recurrent ischemic stroke, so antiplatelet and anticoagulation therapy is generally started 24 hours following TPA treatment. 
• Hyperlipidemia treatment – Because elevated lipids are a risk factor for stroke, patients are likely to receive statin therapy.

Surgical/invasive treatment for ischemic stroke

Large vessel occlusions may be treated with mechanical thrombectomy provided the onset of symptoms is less than 24 hours. 

Review the basics of stroke nursing in episode 25.

Subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) occurs when there is bleeding into the subarachnoid space, making this a type of hemorrhagic stroke. These hemorrhages can be further categorized as traumatic (due to a serious brain injury) and nontraumatic. A nontraumatic SAH may also be referred to as a spontaneous subarachnoid hemorrhage and this type is most often due to a ruptured brain aneurysm, so that is what we will focus on here. 

Individuals suffering from a subarachnoid hemorrhage due to aneurysm rupture often describe their symptoms as “the worst headache of my life.” These headaches come on suddenly and very strongly, which is why they are commonly referred to as “thunderclap headaches.” The patient may also experience nausea and vomiting, loss of consciousness, neck stiffness and focal deficits.

Subarachnoid hemorrhage diagnostics

• Noncontrast head CT – Blood will show on this scan, which you may hear referred to as “a positive CT scan.” A CT scan can also show enlarged ventricles and cerebral edema.
• Lumbar puncture – If the CT scan is normal, a lumbar puncture may be utilized to observe for increased pressure, RBCs in the CSF, and a pink or yellow tint to the CSF (xanthochromia).
• CTA, MRA, MRI – These diagnostic tests may be utilized in patients when the CT scan and/or lumbar puncture results are uncertain.

Medical treatments for subarachnoid hemorrhage

The goals with SAH are to prevent additional bleeding and treat complications. Medical management of this condition can be complex and involve a wide range of therapies. The key goals are listed here, just note you will see other treatments utilized for the wide range of potential complications.

• Blood pressure control – In patients with an unsecured aneurysm that has not yet been surgically treated, blood pressure is tightly controlled. It’s important to note that BP is not dropped rapidly as this can result in decreased cerebral perfusion pressure (CPP) and worsen neurological outcomes. Instead the BP is lowered gradually to the MD’s prescribed parameters. According to UpToDate, this range is SBP < 160 and DBP < 110, though it’s important to note you could see even lower parameters as this is variable based on the patient’s baseline BP, severity of bleeding, presence of cerebral edema and risk for renal impairment. Note that blood pressure control must always be weighed against cerebral perfusion pressure to avoid further neurological deterioration and hypotension must be avoided.
• Reverse anticoagulation – Patients with SAH will have antithrombolytics discontinued and any anticoagulants reversed when possible. Reversal methods utilized are dependent upon the anticoagulant used. For example, if a patient had received antiplatelet medications, then they likely will receive a platelet transfusion. Patients on warfarin receive coagulation factors in the form of fresh frozen plasma (FFP) and/or Vitamin K. If the patient has been taking a DOAC medication such as dabigatran or apixaban receive specific reversal agents for those drugs.
• Maintenance of fluid and electrolyte balance – IV fluids are utilized to achieve fluid balance while electrolytes are replaced to maintain normal levels. In particular, sodium levels may be low, so the standard fluid utilized in SAH is usually 0.9% sodium chloride.
• Prevent vasospasm – Vasospasm is a sudden constriction of a blood vessel. When this occurs in the brain, the tissue experiences reduced blood flow which can worsen neurological function. The medication nimodipine (a dihydropyridine calcium channel blocker), primarily acts as a vasodilator to help keep blood flow optimized. It is administered every four hours around the clock for a period of 21 days.  Note that “triple H” therapy is no longer routinely utilized to prevent vasospasm as studies show inducing hypervolemia can worsen outcomes.
• Maintain optimal CPP – Once the aneurysm has been treated, blood pressures may be increased to improve CPP. This treatment involves the use of vasopressors such as norepinephrine in conjunction with intravenous fluids to maintain euvolemia. Some patients may also require the addition of an inotropic medication such as dobutamine or milrinone. 
• Prevent seizures – Seizure prophylaxis may be utilized initially but, in many cases, is discontinued after the aneurysm has been stabilized or secured (unless, of course, the patient has recurrent seizures). The most commonly utilized antiseizure medication is levetiracetam (Keprra) while phenytoin is generally avoided.

Surgical and invasive treatments for SAH

• Clipping/coiling – The mainstay of treatment for aneurysmal SAH is clipping or coiling of the aneurysm. 
• Ventriculostomy – Patients with cerebral edema or enlarged ventricles require close monitoring of intracranial pressure (ICP) and the ability to drain excess cerebrospinal fluid (CSF). This is achieved via a ventriculostomy and the placement of an EVD (extraventricular drain). 
• Lumbar drainage – CSF can also be drained via a lumbar drain.
• Surgical decompression – In cases where intracranial hypertension cannot be managed with CSF drainage, surgical decompression may be utilized to relieve cerebral pressure. This may be achieved through a craniotomy or craniectomy.

Intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is bleeding that occurs directly into cerebral tissue. This subtype of stroke is associated with high morbidity and mortality, and is the second most common cause of stroke. Some key risk factors include hypertension, use of anticoagulant medications, presence of a coagulation disorder, AVMs, aneurysms, and amyloid angiopathy. It can also occur due to hemorrhagic transformation of an ischemic stroke and trauma.

Intracerebral hemorrhage diagnostics

• CT scan – Noncontrast head CT is utilized to identify ICH and differentiate it from ischemic stroke. A CTA may also be conducted, which can show if there is an underlying vascular cause of the hemorrhage.
• MRI – Brain MRI may also be utilized, though note it is not as readily available and takes quite a bit longer to conduct than a CT scan. One advantage of MRI is that it can help determine the age of the hemorrhage and allow for visualization of lesions associated with ICH.

Medical treatment for ICH

Medical treatments for ICH are aimed at managing bleeding, maintaining normal blood pressure, and maintaining optimal ICP.

• Manage bleeding – Bleeding is managed in ICH by reversing anticoagulation medications, addressing coagulation factor deficiencies and thrombocytopenia.
• Blood pressure management – Hypertension can lead to expansion of the hemorrhage, so blood pressure control is vitally important. Elevated blood pressures are common in individuals with ICH due to increased ICP and pain. Target BP can vary, but general guidelines are:
  • Presenting SBP between 150 and 220 mmHg – Lower SBP to a target of 140 mmHg, ideally within the first hour as long as the patient remains stable.
  • Presenting SBP above 220 mmHg – Rapid lowering of SBP to < 220 mmHg and then gradual reduction to a target range of 140 to 160 mmHg.
• Intracranial pressure management – Medical therapies to manage ICP include preventive measures such as patient positioning, avoidance of fever, use of sedation in agitated patients, and maintaining a normal serum sodium level. When ICP is elevated, osmotic therapy may be warranted. This involves the use of a hypertonic solution such as mannitol or hypertonic saline. 

Surgical/invasive treatments for ICH

• CSF drainage – An EVD may be utilized to drain excess CSF to help maintain optimal ICP.
• Surgery – Surgical decompression may be utilized, especially in those with larger bleeds and in cases of uncontrolled intracranial hypertension. 

Subdural hematoma

A subdural hematoma (SDH) is a type of intracranial hemorrhage that is most often caused by head trauma. As the hematoma grows, it places pressure on the brain, leading to neurological symptoms and deterioration.

Subdural hematoma diagnostics

• Head CT – A noncontrast CT scan of the head is the most widely used diagnostic tool for evaluating SDH.
• MRI – Brain MRI may also be utilized and is especially helpful in identifying smaller bleeds, the duration or age of the bleed, and evaluating for any underlying causes such as an AVM.

Medical treatment for subdural hematoma

Like with other hemorrhagic neurological injuries, a key treatment is to manage and reverse anticoagulation. This can be achieved with reversal agents, administration of coagulation factors or FFP, and stopping any medications that can contribute to bleeding such as aspirin. Patients may also require seizure prophylaxis or treatment, and, in cases of increased ICP, strategies to maintain optimal pressure may be utilized as well (described above in ICH segment).

Surgical/invasive treatments for subdural hematoma

While smaller hematomas that are not encroaching on the brain or brain stem may be treated very conservatively, larger or rapidly expanding hematomas require prompt surgical evacuation. Procedures utilized to surgically treat an SDH include: 

• Craniotomy – Removal of a small portion of the skull to allow for drainage of the hematoma. The skull portion is then replaced at the end of the procedure.
• Craniectomy – In this procedure, the skull portion (also called a skull flap) is not immediately replaced. This helps reduce complications associated with cerebral edema. Once the crisis phase has passed and edema is no longer a risk, the skull flap is replaced. In the meantime, the segment of skull may be preserved subcutaneously in the abdomen or via cryopreservation (frozen). The replacement procedure is called a cranioplasty.
• Craniostomy – Placement of a burr hole, which provides quick access to the hematoma for evacuation. Key advantages of this procedure are that it is less invasive than a craniotomy or craniectomy and can even be done at the bedside in an emergent situation. One downside is that drainage is not as effective as with a craniotomy or craniectomy.

Summary

I hope this overview has helped you with some key similarities and differences between these four common types of neurological injury. Here’s a very brief summary that hits the highlights, but for more details make sure you dive into the sections above!

	Overview	Key Diagnostics	Primary Medical Tx	Surgical Tx
Ischemic stroke	Blockage of blood flow to the brain, often due to blood clot or plaque buildup.	Noncontrast head CT to rule out hemorrhage	TPA (Alteplase)	Mechanical thrombectomy in cases of large vessel occlusion
SAH	Bleeding into the subarachnoid space, usually due to ruptured aneurysm.	Noncontrast head CT  will show the bleed Lumbar puncture	Medical treatments are aimed at controlling blood pressure, reversing anticoagulation, maintaining fluid and electrolyte balance, preventing vasospasm, maintaining optimal CPP, and preventing seizure	Clipping or coiling of aneurysm Ventriculostomy CSF drainage Surgical decompression in severe cases of intracranial hypertension
ICH	Bleeding into the cerebral tissue.	Noncontrast head CT will show the bleed Brain MRI	Medical treatments are aimed at managing bleeding, maintaining normal blood pressure, and maintaining optimal ICP	CSF drainage Surgical decompression in larger bleeds and/or severe cases of intracranial hypertension
SDH	Bleeding into the subdural space, usually due to head trauma.	Noncontrast head CT will show the accumulation of blood Brain MRI (helpful in smaller bleeds)	Reversal of anticoagulation and management of coagulopathies	Surgical decompression and evacuation of the hematoma

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Last Updated on March 14, 2025 by Maureen Osuna, MSN, RN