Table 1 Summary of consensus conference recommendations

1

All exsanguinating patients (life-threatening hemorrhage) require immediate intervention (surgery and/or interventional radiology) for bleeding control.

100

2

Patients without life-threatening hemorrhage or following measures to obtain bleeding control (in case of life-threatening hemorrhage) require urgent neurological evaluation [pupils + Glasgow Coma Scale motor score (if feasible), and brain computed tomography (CT) scan] to determine the severity of brain damage (life-threatening or not).

100

3

After control of life-threatening hemorrhage is established, all salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation and intervention.

100

4

Patients (without or after control of life-threatening hemorrhage) at risk for intracranial hypertension (IH)* (without a life-threatening intracranial mass lesion or after emergency neurosurgery) require intracranial pressure (ICP) monitoring regardless of the need of emergency extra-cranial surgery (EES) [16, 17].

97.5

5

We recommend maintaining systolic blood pressure (SBP) > 100 mmHg or mean arterial pressure (MAP) > 80 mmHg during interventions for life-threatening hemorrhage or emergency neurosurgery. In cases of difficult intraoperative bleeding control, lower value may be tolerated for the shortest possible time.

82.5

6

We recommend red blood cell (RBC) transfusion for hemoglobin (Hb) level < 7 g/dl during interventions for life-threatening hemorrhage or emergency neurosurgery. Higher threshold for RBC transfusions may be used in patients “at risk” (i.e., the elderly and/or patients with limited cardiovascular reserve due to pre-existing heart disease).

97.5

7

We recommend maintaining an arterial partial pressure of oxygen (PaO2) level between 60 and 100 mmHg during interventions for life-threatening hemorrhage or emergency neurosurgery.

95

8

We recommend maintaining an arterial partial pressure of carbon dioxide (PaCO2) level between 35 and 40 mmHg during interventions for life-threatening hemorrhage or emergency neurosurgery.

97.5

9

In cases of cerebral herniation, awaiting or during emergency neurosurgery, we recommend the use of osmotherapy and/or hypocapnia (temporarily).

90

10

In cases requiring intervention for life-threatening systemic hemorrhage, we recommend, at a minimum, the maintenance of a platelet (PLT) count > 50.000/mm³. In cases requiring emergency neurosurgery (including ICP probe insertion), a higher value is advisable.

100

11

We recommend maintaining a prothrombin time (PT)/activated partial thromboplastin time (aPTT) value of < 1.5 normal control during interventions for life-threatening hemorrhage or emergency neurosurgery (including ICP probe insertion).

92.5

12

We recommend, if available, that Point-of-Care (POC) tests [e.g., thromboelastography (TEG) and rotational thromboelastometry ROTEM] be utilized to assess and optimize coagulation function during interventions for life-threatening hemorrhage or emergency neurosurgery (including ICP probe insertion).

90

13

During massive transfusion protocol initiation, we recommend the transfusion of RBCs/plasma/PLTs at a ratio of 1/1/1. Afterwards, this ratio may be modified according to laboratory values.

92.5

14

We recommend maintaining a cerebral perfusion pressure (CPP) ≥ 60 mmHg when ICP monitoring becomes available. This value should be adjusted (individualized) based on neuromonitoring data and the cerebral autoregulation status of the individual patient.

95

15

In the absence of possibilities to target the underlying pathophysiologic mechanism of IH, we recommend a stepwise approach [18], where the level of therapy, in patients with elevated ICP, is increased step by step, reserving more aggressive interventions, which are generally associated with greater risks/adverse effects, for situations when no response is observed.

97.5

16

We recommend the development of protocols, in conjunction with local resources and practices, to encourage the implementation of a simultaneous multisystem surgery (SMS) [including radiologic interventional procedures] in patients requiring both intervention for life-threatening hemorrhage and emergency neurosurgery for life-threatening brain damage.

100