What are the immediate management steps for a cerebral vascular accident (CVA) bleed?

Immediate Management of Hemorrhagic Stroke (CVA Bleed)

For hemorrhagic stroke, immediately perform neurological assessment (pupils, GCS motor score) and obtain urgent brain CT scan, maintain systolic blood pressure >100 mmHg (MAP >80 mmHg), obtain neurosurgical consultation for life-threatening lesions, and initiate ICP monitoring in comatose patients with radiological signs of intracranial hypertension. 1

Initial Assessment and Stabilization

Neurological Evaluation

• Conduct immediate neurological assessment using NIHSS for awake/drowsy patients or Glasgow Coma Scale for obtunded patients to establish baseline severity, which strongly predicts outcomes 2
• Assess pupils, GCS motor score (if feasible), and perform urgent brain CT scan to determine severity of brain damage 1
• Repeat validated neurological assessments (such as CNS score) at least hourly for the first 24 hours, adjusting frequency based on patient stability 2
• Assess for clinical signs of increased intracranial pressure including altered mental status, pupillary changes, and posturing 2

Diagnostic Imaging

• Perform CT or MRI immediately to confirm diagnosis, location, and extent of hemorrhage 2
• Obtain CT angiography, MR angiography, or catheter angiography for most patients to exclude underlying lesions such as aneurysms or arteriovenous malformations 2
• Be aware that 30-40% of patients experience hematoma expansion, which predicts poor outcome; risk factors include contrast extravasation ("spot sign"), early presentation, anticoagulation use, and initial hematoma volume 2

Blood Pressure Management

Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during all interventions 1

• Assess blood pressure on initial arrival and every 15 minutes thereafter until stabilized 2
• Blood pressure targets require careful monitoring and may necessitate aggressive repeated dosing or intravenous infusion of antihypertensive medications 2
• In cases of difficult bleeding control, lower values may be tolerated for the shortest possible time 1

Laboratory Assessment

Immediate Studies

• Obtain complete blood count, platelet count, PT, aPTT, INR, and fibrinogen levels immediately 2
• Obtain detailed medication history, particularly regarding anticoagulant and antiplatelet therapy 2
• Perform early, repeated measurements of PT, aPTT, fibrinogen, and platelets to detect coagulopathy 2
• Measure serum lactate and base deficit to estimate and monitor the extent of bleeding and tissue hypoperfusion 1
• Do not rely on single hemoglobin/hematocrit measurements alone as isolated markers for bleeding severity, as they lag behind acute blood loss 1

Transfusion Thresholds

Transfuse red blood cells when hemoglobin level falls below 7 g/dL during interventions 1

• Higher threshold for RBC transfusions may be used in elderly patients and/or patients with limited cardiovascular reserve due to pre-existing heart disease 1
• Maintain platelet count >50,000/mm³ for life-threatening systemic hemorrhage; higher values are advisable for emergency neurosurgery including ICP probe insertion 1

Respiratory Management

• Optimize respiratory effort and maintain adequate oxygenation 2
• Maintain arterial partial pressure of oxygen (PaO₂) between 60 and 100 mmHg 1
• Maintain arterial partial pressure of carbon dioxide (PaCO₂) between 35 and 40 mmHg 1
• Apply initial normoventilation if there are no signs of imminent cerebral herniation 2
• Do not hyperventilate severely hypovolemic patients or subject them to excessive positive end-expiratory pressure 1

Management of Intracranial Hypertension

Patients at risk for intracranial hypertension (comatose with radiological signs of IH) require ICP monitoring regardless of need for emergency extra-cranial surgery 1

• In cases of cerebral herniation, awaiting or during emergency neurosurgery, use osmotherapy and/or hypocapnia temporarily 1

Neurosurgical Intervention

After control of any life-threatening hemorrhage, all salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation and intervention 1

• There is no compelling evidence that surgical evacuation of supratentorial intraparenchymal hematoma is beneficial in most cases 2
• However, hematoma evacuation may alleviate impending brain herniation in selected individuals 2

Coagulopathy Reversal

• Consider tranexamic acid 10-15 mg/kg followed by an infusion of 1-5 mg/kg/h in bleeding patients 3
• Implement early measures to reduce heat loss and warm hypothermic patients to achieve and maintain normothermia 3

Ongoing Monitoring

• Continue neurological assessments hourly for the first 24 hours 2
• Monitor for signs of rebleeding, increased intracranial pressure, and neurological deterioration 2
• Assess for development of complications including seizures and cerebral edema 2
• Insert urinary catheter and monitor hourly urine output (target >30 mL/hour) in hemodynamically compromised patients 3

Critical Pitfalls to Avoid

• Never delay neurological evaluation and brain CT scan once any life-threatening hemorrhage is controlled 1
• Avoid hypotension below SBP 100 mmHg or MAP 80 mmHg, as this compromises cerebral perfusion pressure 1
• Do not rely solely on blood pressure measurements, as some patients compensate well despite significant hemorrhage 3
• Minimize time between symptom onset and diagnostic evaluation 3