What are the latest guidelines for diagnosing and managing cerebral vascular accident (CVA) bleed?

Diagnosis and Management of Cerebrovascular Accident (CVA) Bleed

The diagnosis of cerebrovascular accident (CVA) bleed requires immediate assessment using established grading systems, focused neuroimaging, and laboratory studies, followed by prompt intervention based on the identified source and severity of bleeding. 1

Initial Assessment and Diagnosis

Clinical Evaluation

• Assess the extent of bleeding using an established grading system such as the Advanced Trauma Life Support (ATLS) classification 2
• Evaluate vital signs, mental status, and neurological deficits to determine severity 1
• Minimize time between symptom onset and diagnostic evaluation 1

Laboratory Assessment

• Obtain baseline coagulation studies including PT/INR, aPTT, fibrinogen, and platelet count 1
• Do not rely on single hematocrit measurements as an isolated marker for bleeding 1
• Measure serum lactate and base deficit to estimate and monitor the extent of bleeding and shock 1
• Consider early, repeated hemostasis monitoring in patients with suspected coagulopathy 1

Imaging Studies

• For patients with suspected CVA bleed, perform immediate CT scan of the head 1
• Early focused sonography (FAST) should be employed for detection of free fluid in patients with suspected torso trauma 1
• Pre-hospital ultrasonography may be used if feasible without delaying transport 1
• Hemodynamically stable patients with suspected head, chest, or abdominal bleeding following high-energy injuries should undergo further assessment using CT 1

Management Based on Bleeding Source

Immediate Intervention

• Patients with identified source of bleeding and hemodynamic instability should undergo immediate bleeding control procedure 1
• Patients with unidentified source of bleeding should undergo immediate further investigation 1

Intraventricular Hemorrhage Management

• Evaluate for acute obstructive hydrocephalus, which poses an immediate threat to life 3
• Consider external ventricular drainage (EVD) through an intraventricular catheter if hydrocephalus is contributing to neurological decline 3
• Assess clotting function before inserting an intraventricular catheter 3

Blood Pressure Management

• For patients without brain injury, employ a restricted volume replacement strategy with target systolic blood pressure of 80-90 mmHg (MAP 50-60 mmHg) until major bleeding has been stopped 1
• For patients with severe traumatic brain injury (GCS <8), maintain a mean arterial pressure ≥80 mmHg 1
• Administer noradrenaline in addition to fluids if a restricted volume strategy fails to maintain target arterial pressure 1

Fluid Resuscitation and Blood Products

Fluid Therapy

• Initiate fluid therapy using 0.9% NaCl or balanced crystalloid solution 1
• Avoid hypotonic solutions such as Ringer's lactate in patients with severe head trauma 1
• Restrict use of colloids due to adverse effects on hemostasis 1

Blood Product Administration

• If erythrocyte transfusion is necessary, aim to achieve a target hemoglobin of 70-90 g/L 1
• Consider cell salvage in the presence of severe bleeding from an abdominal, pelvic, or thoracic cavity 1

Management of Coagulopathy

Antifibrinolytic Agents

• Consider tranexamic acid 10-15 mg/kg followed by an infusion of 1-5 mg/kg/h in bleeding patients 1
• Alternative options include ε-aminocaproic acid 100-150 mg/kg followed by 15 mg/kg/h 1

Temperature Management

• Implement early measures to reduce heat loss and warm the hypothermic patient to achieve and maintain normothermia 1
• Actively warm all transfused fluids 2

Special Considerations

Surgical Management

• Damage-control surgery should be performed in severely injured patients presenting with hemorrhagic shock, signs of ongoing bleeding, coagulopathy, vascular injuries, hypothermia, or acidosis 1
• For patients with pelvic ring disruption in hemorrhagic shock, perform immediate pelvic ring closure and stabilization 1
• Patients with ongoing hemodynamic instability despite adequate pelvic ring stabilization should receive early angiographic embolization or surgical bleeding control 1

Thromboprophylaxis

• Apply early mechanical thromboprophylaxis with intermittent pneumatic compression while the patient is immobile and has bleeding risk 1
• Implement combined pharmacological and intermittent pneumatic compression within 24 hours after bleeding has been controlled 1
• Avoid graduated compression stockings and routine use of inferior vena cava filters 1

Common Pitfalls and Caveats

• Avoid delays between injury and surgical intervention for patients requiring urgent bleeding control 2
• Do not rely solely on blood pressure as an indicator of blood loss, as some patients compensate well despite significant hemorrhage 2
• Avoid hyperventilation and excessive positive end-expiratory pressure in severely hypovolemic patients 1, 2
• The routine use of point-of-care platelet function monitoring devices should be avoided in trauma patients on antiplatelet therapy 1