What is the treatment for hemorrhagic cerebral vascular accident (CVA)?

Hemorrhagic CVA Treatment

Immediately target systolic blood pressure to 130-150 mmHg upon diagnosis, reverse any anticoagulation with specific agents, admit to a comprehensive stroke unit, and consult neurosurgery for large hematomas with mass effect or obstructive hydrocephalus. 1

Immediate Emergency Management (First Minutes to Hours)

Blood Pressure Control

• Target systolic blood pressure of 130-150 mmHg immediately upon diagnosis 1
• Avoid aggressive lowering below 130 mmHg systolic, as this compromises cerebral perfusion and worsens outcomes 1
• Use intravenous beta-blockers (labetalol, esmolol, metoprolol) as first-line agents for rapid control 2

Anticoagulation Reversal

• Immediately reverse ongoing anticoagulant therapy with dedicated reversal agents: 1
  • Prothrombin complex concentrate for warfarin 1
  • Factor VIIa for specific indications 1
  • Specific reversal agents (idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors) 1
• Do NOT give platelet transfusions for patients on single or dual antiplatelet therapy—this is not supported by evidence and may be harmful 1

Diagnostic Imaging

• Obtain immediate non-contrast CT to confirm hemorrhage location, size, and presence of mass effect 3
• Assess for intraventricular extension, hydrocephalus, and midline shift 1

Acute Hospital Phase (First 24-48 Hours)

Admission and Monitoring

• Admit ALL patients to a comprehensive stroke unit regardless of hemorrhage severity—this single intervention reduces mortality and improves functional outcomes 1
• Continuously monitor intracranial pressure, cerebral perfusion pressure, and hemodynamic function 1
• Watch for hematoma expansion, which occurs most frequently in the first hours and is associated with neurologic deterioration 3

Swallowing and Nutrition

• Perform swallowing assessment before allowing ANY oral intake to prevent aspiration pneumonia, which significantly increases mortality 1, 4
• Use nasogastric or nasoduodenal tube feeding for patients with impaired swallowing 4

Neurosurgical Consultation

• Obtain immediate neurosurgical consultation for: 1
  • Large hematomas with mass effect causing neurological deterioration
  • Obstructive hydrocephalus requiring external ventricular drainage
  • Cerebellar hemorrhages with brainstem compression

Specific Hemorrhagic Stroke Subtypes

Intraventricular Hemorrhage

• Place external ventricular drainage with antibiotic-coated or bolted catheters—these are superior to tunneled/uncoated catheters in preventing infection 1
• Consider intraventricular fibrinolysis, which decreases mortality and improves functional outcomes 1

Cerebral Venous Thrombosis with Hemorrhage

• This is a critical exception: INITIATE anticoagulation with IV heparin or subcutaneous LMWH even if intracranial hemorrhage is present 4, 5, 6
• Hemorrhage from cerebral venous thrombosis is NOT a contraindication to anticoagulation—withholding anticoagulation can lead to catastrophic thrombotic progression 1, 4
• Anticoagulation can be safely initiated in clinically stable patients with non-temporal-lobe hemorrhagic infarction of unchanging volume on serial CT 6
• Avoid anticoagulation only if: temporal lobe location, midline shift present, or enlarging hematoma 6
• Continue oral anticoagulation for 3-12 months depending on underlying etiology 4

Surgical Intervention Considerations

Indications for Surgery

• Superficial arteriovenous malformations (AVMs) presenting with hemorrhage, particularly Spetzler-Martin grades I and II, benefit from microsurgery with low morbidity and immediate cure 7
• Emergency hematoma evacuation is indicated only for superficial AVMs where anatomy can be readily elucidated; otherwise, stabilize first 7
• Conventional craniotomy for hematoma evacuation does not improve outcomes, but minimally invasive techniques may be valuable 3

Timing of Surgery

• AVM microsurgery is generally elective unless life-threatening hemorrhage or hydrocephalus is present 7
• For emergent cases, resolve hemorrhage-related complications first, followed by rehabilitation and angiographic analysis before definitive treatment 7

Rehabilitation and Long-term Management

Early Mobilization

• Begin early mobilization as soon as medically stable 1
• Initiate physical, occupational, and speech therapy assessments immediately 1

Secondary Prevention

• Implement aggressive blood pressure control after the acute phase 1
• Manage all vascular risk factors including diabetes and hyperlipidemia 1
• Use subcutaneous anticoagulants or intermittent external compression stockings to prevent deep vein thrombosis in immobilized patients 4

Critical Pitfalls to Avoid

• Never withhold anticoagulation in cerebral venous thrombosis even if hemorrhage is present—this common misconception can be catastrophic 1, 4
• Never aggressively lower blood pressure below 130 mmHg systolic—this worsens outcomes by compromising cerebral perfusion 1
• Never allow oral intake before swallowing assessment—aspiration pneumonia significantly increases mortality 1, 4
• Never give platelet transfusions for antiplatelet therapy-associated hemorrhage—this is not evidence-based 1
• Never delay neurosurgical consultation for large hematomas with mass effect or obstructive hydrocephalus 1