What is the initial management for a patient presenting with hemorrhagic Cerebrovascular Accident (CVA)?

Initial Management of Hemorrhagic Cerebrovascular Accident (CVA)

Patients with intracerebral hemorrhage (ICH) must be treated as a medical emergency and evaluated immediately by physicians with expertise in hyperacute stroke management. 1

Immediate Assessment and Stabilization

Neurological Evaluation

• Conduct an NIHSS on awake or drowsy patients, or a GCS on obtunded/comatose patients as part of initial assessment to determine baseline severity of neurological impairments, which is a strong predictor of outcomes following ICH 1
• Repeat validated neurological scale assessments (such as CNS score) at baseline and at least hourly for the first 24 hours, depending on patient stability 1
• Assess for clinical signs of increased intracranial pressure 1

Diagnostic Imaging

• Obtain CT or MRI immediately to confirm diagnosis, location, and extent of hemorrhage 1, 2
• In patients with confirmed acute ICH, perform CT angiography, MR angiography, or catheter angiography to exclude underlying lesions such as aneurysm or arteriovenous malformation 1
• This vascular imaging is particularly important for: lobar ICH in patients <70 years, deep/posterior fossa ICH in patients <45 years, or deep/posterior fossa ICH in patients 45-70 years without hypertension history 1

Laboratory Assessment

• Evaluate anticoagulant therapy history, measure platelet count, partial thromboplastin time (PTT), and INR 1
• Obtain complete blood count and blood glucose 2
• Document medication history, particularly anticoagulant or antiplatelet agents 1

Blood Pressure Management

Blood pressure should be assessed on initial arrival to the ED and every 15 minutes thereafter until stabilized 1

Target Blood Pressure

• For patients with systolic blood pressure 150-220 mmHg presenting within 6 hours of symptom onset, acutely lower SBP to a target of 140 mmHg (strictly avoiding SBP <110 mmHg) to reduce risk of hematoma expansion 1, 2
• Blood pressure targets may be challenging to achieve and require careful monitoring, and in some cases aggressive repeated dosing or intravenous infusion of antihypertensive medications 1
• Continue close blood pressure monitoring (every 30-60 minutes, or more frequently if above target) for at least the first 24-48 hours 1

Preferred Antihypertensive Agents

• Use small boluses of labetalol for hypertension management 2
• Nicardipine can be easily titrated but caution is advised to avoid systemic hypotension when administering to patients who have sustained acute cerebral hemorrhage 3
• Avoid antihypertensive agents that induce cerebral vasodilation in patients with markedly elevated intracranial pressure 2

Reversal of Coagulopathy

Anticoagulation should be discontinued immediately and reversed as soon as possible in anticoagulant-associated ICH 1

Warfarin-Associated ICH

• For VKA-associated ICH with INR ≥2.0, administer 4-factor prothrombin complex concentrate (4F-PCC) over fresh-frozen plasma (FFP) 1, 2
• Use FFP or 3F-PCC when 4F-PCC is not available 1
• Administer intravenous vitamin K shortly after 4F-PCC or FFP to prevent later re-emergence of anticoagulation 1, 2

Direct Oral Anticoagulant-Associated ICH

• For dabigatran reversal, use idarucizumab 1
• For factor Xa inhibitor reversal, use andexanet alpha or, if not available, 4F-PCC 1

Heparin-Associated ICH

• Administer protamine sulfate for heparin-related ICH 1

Platelet Dysfunction

• Patients with severe thrombocytopenia should receive appropriate platelet transfusion 2

Fluid Management

• Use isotonic fluids (0.9% NaCl or balanced crystalloid solution) to maintain hydration while preventing volume overload 4, 2
• Avoid hypo-osmolar fluids such as 5% dextrose in water as they may worsen cerebral edema 2
• Avoid Ringer's lactate, Ringer's acetate, and gelatins as they are hypotonic in terms of real osmolality 2
• Do not use albumin or other synthetic colloids in early management 2

Management of Increased Intracranial Pressure

• Elevate the head of the bed by 20-30 degrees to help venous drainage 2
• Treat factors that exacerbate raised intracranial pressure including hypoxia, hypercarbia, and hyperthermia 2
• Consider osmotherapy for patients whose condition is deteriorating due to increased intracranial pressure 2
• In cases of intraventricular hemorrhage (IVH) with hydrocephalus contributing to decreased level of consciousness, external ventricular drainage is recommended 1

Surgical Considerations

• Obtain prompt neurosurgical consultation for evaluation of potential surgical interventions 2
• Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible 2
• Patients with massive cerebral or cerebellar hemorrhage or at risk of malignant swelling should be rapidly transferred to a center with neurosurgical expertise if their condition is deemed survivable 1

Venous Thromboembolism Prophylaxis

Implement intermittent pneumatic compression (IPC) for prevention of venous thromboembolism beginning the day of hospital admission 2, 5

• Apply early mechanical thromboprophylaxis with intermittent pneumatic compression while the patient is immobile and has bleeding risk 4
• After documentation of bleeding cessation, early initiation of pharmacological VTE prophylaxis (24-48 hours from ICH onset) appears safe and effective 5
• Gradient compression stockings are not recommended by current guidelines 5

Seizure Management

• Treat new-onset seizures occurring within 24 hours of stroke onset with appropriate short-acting medications 2
• Single, self-limiting seizures at onset or within 24 hours should not receive long-term anticonvulsant medications 2
• Prophylactic administration of anticonvulsants is not recommended 2
• Antiseizure medications are only indicated for documented secondary seizures 1

Temperature and Metabolic Management

• Monitor body temperature and treat fever (temperature >38°C); investigate and treat sources of fever 1, 2
• Promptly measure serum glucose and correct hypoglycemia immediately 2
• Implement early measures to reduce heat loss and warm hypothermic patients to achieve and maintain normothermia 4

Monitoring and Care Setting

• Provide initial monitoring and management in an intensive care unit or dedicated stroke unit with physician and nursing neuroscience acute care expertise 2
• Conduct formal screening for dysphagia before initiating oral intake to reduce the risk of pneumonia 2

Critical Pitfalls to Avoid

• Be vigilant for early deterioration, which is common in the first few hours after ICH onset 2
• Monitor for hematoma expansion, which occurs in 30-40% of patients and is a predictor of poor outcome; risk factors include 'spot sign' on imaging, early presentation, anticoagulation use, and initial hematoma volume 1
• Avoid delaying imaging or treatment decisions while waiting for diagnostic test results 2
• Do not transfer patients who are hypotensive and actively bleeding; control hemorrhage before transfer 2
• Avoid aggressive blood pressure lowering that drops SBP below 110 mmHg 1