What is the management for a cerebral vascular accident (CVA) bleed?

Management of Hemorrhagic Cerebrovascular Accident (CVA)

For hemorrhagic CVA, initiate conservative management with immediate neurological assessment, blood pressure control, coagulopathy reversal, and supportive care—surgical evacuation is not beneficial in most supratentorial hemorrhages but may be considered for impending herniation. 1

Immediate Assessment and Stabilization

Neurological Evaluation

• Perform NIHSS scoring in awake or drowsy patients, or Glasgow Coma Scale in obtunded patients immediately upon presentation to establish baseline severity, which strongly predicts outcomes 1
• Repeat validated neurological assessments (such as CNS score) at minimum hourly intervals for the first 24 hours, adjusting frequency based on patient stability 1
• Assess specifically for clinical signs of increased intracranial pressure including pupillary changes, posturing, and deteriorating consciousness 1

Diagnostic Imaging

• Obtain non-contrast CT or MRI immediately to confirm diagnosis, determine hemorrhage location, and measure hematoma volume 1
• Perform CT angiography, MR angiography, or catheter angiography in most patients to exclude underlying structural lesions such as aneurysms or arteriovenous malformations 1

Blood Pressure Management

• Measure blood pressure on initial arrival and repeat every 15 minutes until stabilized 1
• Implement aggressive repeated dosing or continuous intravenous infusion of antihypertensive medications to achieve target blood pressure, with careful monitoring required 1
• Critical caveat: 30-40% of patients experience hematoma expansion within the first hours, which is a major predictor of poor outcome—risk factors include contrast extravasation ("spot sign"), early presentation (<3 hours), anticoagulation use, and larger initial hematoma volume 1

Coagulopathy Reversal

Laboratory Assessment

• Obtain platelet count, partial thromboplastin time (PTT), and INR immediately upon presentation 1
• Perform early, repeated measurements of PT, APTT, fibrinogen, and platelets to detect evolving coagulopathy 1
• Document detailed medication history, particularly all anticoagulant and antiplatelet agents 1

Pharmacologic Interventions

• Consider tranexamic acid 10-15 mg/kg bolus followed by continuous infusion of 1-5 mg/kg/hour in bleeding patients 2
• Reverse anticoagulation based on specific agent used (vitamin K and prothrombin complex concentrate for warfarin, idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors) 1

Fluid Resuscitation and Blood Products

• Initiate fluid therapy using 0.9% NaCl or balanced crystalloid solution 2
• If erythrocyte transfusion becomes necessary, target hemoglobin of 70-90 g/L rather than higher thresholds 2
• For patients without brain injury and ongoing bleeding, employ restricted volume replacement strategy targeting systolic blood pressure 80-90 mmHg (MAP 50-60 mmHg) until bleeding is controlled 2

Temperature Management

• Implement early measures to reduce heat loss and actively warm hypothermic patients to achieve and maintain normothermia, as hypothermia worsens coagulopathy 2

Respiratory Support

• Optimize respiratory effort and maintain adequate oxygenation with supplemental oxygen as needed 1
• Apply initial normoventilation if no signs of imminent cerebral herniation are present 1
• Intubate for airway protection if Glasgow Coma Scale ≤8 or signs of impending herniation develop 1

Surgical Considerations

There is no compelling evidence that surgical evacuation of supratentorial intraparenchymal hematoma improves outcomes in most cases 1

However, hematoma evacuation may be considered in selected individuals to:

• Alleviate impending brain herniation with rapid neurological deterioration 1
• Decompress posterior fossa hemorrhages causing brainstem compression 1

Ongoing Monitoring and Complications

Continuous Assessment

• Continue hourly neurological assessments for the first 24 hours minimum 1
• Monitor for signs of rebleeding, increased intracranial pressure, and progressive neurological deterioration 1
• Assess for development of seizures and cerebral edema 1

Thromboprophylaxis

• Apply early mechanical thromboprophylaxis with intermittent pneumatic compression while the patient remains immobile and has ongoing bleeding risk 2
• Delay pharmacologic anticoagulation until bleeding risk has substantially decreased 2