What is the treatment for a hemorrhagic Cerebrovascular Accident (CVA)?

Treatment of Hemorrhagic Cerebrovascular Accident (CVA)

The primary treatment for hemorrhagic CVA is conservative management with immediate blood pressure control targeting systolic BP 130-150 mmHg, immediate reversal of any anticoagulation, and admission to a comprehensive stroke unit with neurosurgical consultation available. 1

Immediate Emergency Management

Blood Pressure Control

• Target systolic blood pressure of 130-150 mmHg immediately upon diagnosis 1
• Avoid very intense and rapid blood pressure lowering below this optimal range, as it is potentially harmful in the acute phase 1
• Use arterial line monitoring for precise blood pressure management 2
• Maintain normotensive and euvolemic status using arterial catheter monitoring and indwelling urinary catheter 3

Reversal of Anticoagulation

• Immediately reverse ongoing anticoagulant treatment with dedicated reversal agents (prothrombin complex concentrate, factor VIIa, or specific reversal agents depending on the anticoagulant used) 1
• Administer fresh frozen plasma, cryoprecipitates, or antifibrinolytic agents (tranexamic acid or aminocaproic acid) as needed 1
• Platelet transfusions are NOT recommended in patients receiving single or dual antiplatelet therapy 1

Imaging and Diagnosis

• Perform immediate CT imaging to confirm hemorrhage, assess hematoma volume, and rule out ischemic stroke 4, 3
• Consider digital subtraction angiography (DSA) if underlying vascular malformation is suspected, as it remains the gold standard for detailed vascular assessment 3
• MRI provides superior soft tissue detail for identifying underlying structural causes 3

Acute Hospital Phase

Monitoring and Supportive Care

• Admit all patients to a comprehensive stroke unit regardless of hemorrhage severity—this intervention alone reduces mortality and improves functional outcomes 1, 4
• Transfer to Neurological ICU for at least 24 hours to detect complications including rebleeding, cerebral edema, or hydrocephalus 2, 3
• Monitor intracranial pressure (ICP), cerebral perfusion pressure, and hemodynamic function continuously 1
• Watch for cerebral edema (peaks at 3-5 days but can occur earlier with large hemorrhages) 4
• Implement early swallowing assessment before allowing any oral intake to prevent aspiration pneumonia 4

Treatment Goals

• Prevent further bleeding 1
• Evacuate hematoma and reduce mass effect when indicated 1
• Maintain normal ICP to preserve cerebral perfusion pressure and reduce secondary brain injury 1

Specific Hemorrhagic Stroke Subtypes

Intraventricular Hemorrhage (IVH)

• Place external ventricular drainage (EVD) with antibiotic-coated or bolted catheters (superior to tunneled/uncoated catheters in preventing infection, P < 0.001) 1
• Consider intraventricular fibrinolysis (IVF), which decreases mortality (22.4% vs. 40.9% without IVF, P < 0.00001) and improves functional outcomes (47.2% vs. 38.3%, P = 0.03) 1
• IVF reduces catheter occlusion from 37.3% to 10.6% (P = 0.0003) 1

Cerebral Venous Thrombosis with Hemorrhage

• Initiate anticoagulation with IV heparin or subcutaneous LMWH even if intracranial hemorrhage is present—hemorrhage from CVT is NOT a contraindication to anticoagulation 4, 5
• Use adjusted-dose intravenous heparin infusion or subcutaneous enoxaparin 1 mg/kg twice daily 5
• Continue oral anticoagulation for 3-12 months depending on underlying etiology 4

Arteriovenous Malformation (AVM) with Rupture

• Annual rupture risk increases to 6-18% in the first year following initial hemorrhage and 25% after a second bleed 3
• Microsurgery provides immediate hemorrhage risk reduction for small lesions in non-eloquent locations 3
• Pre-operative embolization reduces intraoperative blood loss and surgical complexity when used as adjunct to surgery 3
• Post-treatment angiography is mandatory to confirm complete obliteration 3

Surgical Intervention Considerations

Indications for Neurosurgical Consultation

• Large hematomas with mass effect causing neurological deterioration 1
• Obstructive hydrocephalus requiring EVD placement 1
• Posterior fossa hemorrhages with brainstem compression 1
• Underlying vascular malformations requiring definitive treatment 3

Timing

• Immediate neurosurgical intervention must be available for acute deterioration 2
• For non-urgent cases with AVMs, delay surgery until acute hemorrhage resolves when possible 3

Critical Pitfalls to Avoid

• Never withhold anticoagulation in cerebral venous thrombosis even if hemorrhage is present—this is a common and dangerous misconception that can lead to catastrophic thrombotic progression 4, 5
• Never aggressively lower blood pressure below 130 mmHg systolic—this can worsen outcomes by compromising cerebral perfusion 1
• Never allow oral intake before swallowing assessment—aspiration pneumonia significantly increases mortality 4
• Never give platelet transfusions for antiplatelet therapy-associated hemorrhage—evidence does not support this practice 1
• Never delay imaging or neurosurgical consultation—time-sensitive interventions can be life-saving 4, 3

Rehabilitation and Long-term Management

• Begin early mobilization as soon as medically stable 4
• Initiate physical, occupational, and speech therapy assessments immediately 4
• Use subcutaneous anticoagulants or intermittent external compression stockings to prevent deep vein thrombosis in immobilized patients 4
• Implement aggressive secondary prevention measures including blood pressure control and management of vascular risk factors after the acute phase 4