What medications are used to manage hemorrhagic cerebral vascular accident (CVA)?

Management of Hemorrhagic Cerebrovascular Accident (CVA)

Critical Initial Priorities

The primary management of hemorrhagic CVA focuses on blood pressure control, reversal of anticoagulation if present, and supportive care to prevent secondary brain injury—surgical intervention is reserved for specific indications such as cerebellar hemorrhage with mass effect or deteriorating neurological status despite medical management.

Blood Pressure Management

Target systolic blood pressure <160 mmHg for patients with hemorrhagic stroke to minimize hematoma expansion while maintaining adequate cerebral perfusion. 1

• For patients NOT receiving thrombolysis (which would not apply to hemorrhagic CVA), maintain systolic BP <220 mmHg if being transferred for other interventions 1
• Long-term blood pressure control should target <140/90 mmHg, or <130/80 mmHg for diabetic patients 2
• Use angiotensin-converting enzyme (ACE) inhibitors alone or in combination with a diuretic, or angiotensin receptor blockers (ARBs) for long-term management 2

Common pitfall: Avoid permissive hypotension strategies in patients with traumatic brain injury causing hemorrhagic CVA, as cerebral perfusion pressure must be maintained with mean arterial pressure ≥80 mmHg 3

Reversal of Anticoagulation

For patients on anticoagulants presenting with hemorrhagic CVA, immediate reversal is life-saving:

Vitamin K Antagonists (Warfarin)

• Administer vitamin K and four-factor prothrombin complex concentrate (PCC) for real-time reversal 4
• This provides immediate repletion of clotting factors and stops bleeding progression 4

Direct Oral Anticoagulants (DOACs)

• For dabigatran (thrombin inhibitor): Administer idarucizamab as the specific antidote 4
• For apixaban or rivaroxaban (Factor Xa inhibitors): Administer andexanet alfa as the indicated antidote 4

Airway and Respiratory Management

Intubation is indicated for: 1

• Glasgow Coma Scale (GCS) ≤8
• Deteriorating conscious level (fall in GCS of ≥2 points or motor score of ≥1 point)
• Loss of protective laryngeal reflexes
• Inability to maintain PaO2 ≥13 kPa or peripheral oxygen saturation ≥95%

Target parameters if intubated: 1

• PaCO2: 4.5-5.0 kPa (avoid hyperventilation except briefly for impending uncal herniation, where PaCO2 4.0-4.5 kPa may be used)
• PaO2: ≥13 kPa or oxygen saturation ≥95%
• Use minimum 5 cmH2O PEEP to prevent atelectasis 3

Fluid Resuscitation (If Concurrent Hemorrhagic Shock)

• Begin immediate fluid resuscitation with isotonic crystalloids (0.9% saline) 3
• Avoid hypotonic solutions such as Ringer's lactate in patients with head trauma 3
• Target mean arterial pressure ≥80 mmHg to maintain cerebral perfusion 3
• Consider vasopressors (metaraminol or norepinephrine) if fluid resuscitation alone is inadequate 3, 5

Medications to AVOID in Hemorrhagic CVA

Do not administer antifibrinolytic agents (tranexamic acid, aminocaproic acid) for intracranial hemorrhage, as available data suggest they are more harmful than beneficial. 6

Avoid high-dose glucocorticoids after severe traumatic brain injury causing hemorrhagic CVA, as they increase mortality. 2, 3

Seizure Management

• Antiseizure medications are only indicated for documented secondary seizures, NOT for primary prevention 2
• If seizure occurs, load with levetiracetam 1 g or phenytoin 20 mg/kg (max 2 g) 2

Increased Intracranial Pressure Management

For signs of increased ICP with impending herniation: 3

• Consider mannitol 0.5 g/kg OR hypertonic saline 2 ml/kg of 3% saline
• Position patient with 20-30° head-up tilt if no spinal injury suspected 3
• Consider short-term hyperventilation (PaCO2 not less than 4 kPa) only for acute herniation 3

Diagnostic Workup

• Obtain urgent CT head to evaluate extent of hemorrhage and mass effect 3
• Consider CT angiography if vascular malformation or aneurysm suspected 3
• Obtain complete blood count, coagulation profile, and blood gas analysis 3

Surgical Considerations

Immediate surgical intervention is indicated for: 3

• Cerebellar hemorrhage with mass effect and neurological deterioration
• Significant intraventricular hemorrhage requiring external ventricular drainage
• Accessible superficial lobar hemorrhages with progressive neurological decline despite medical management

The key distinction from ischemic stroke: Hemorrhagic CVA is a contraindication to thrombolysis and anticoagulation (except in the specific case of cerebral venous thrombosis, which is managed differently) 1