Consultation with a neurosurgeon is indicated for all patients. Almost all agree that a patient who is comatose, flaccid, and without brainstem reflexes with a large midline hemorrhage has a poor prognosis. For such patients, basic supportive care may be the only indicated therapy. However, clear consensus does not exist regarding many patients who fall between these extremes. Variation in surgical treatment exists even within a geographic region.
Immediate management consists of stabilization and resuscitation.
Oxygen supplementation may be indicated. Perform endotracheal intubation if required for airway management in patients with a decreased level of consciousness. Correct fluid deficit with isotonic saline. Ventriculostomy is indicated in patients with hemorrhage and hydrocephalus. Patients with a large central clot and absent brainstem reflexes have a poor prognosis.