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

Initial Management of Cerebrovascular Accident (CVA) Bleed

For hemorrhagic stroke, immediately assess neurological status using NIHSS (for awake/drowsy patients) or Glasgow Coma Scale (for obtunded patients), obtain emergent CT imaging to confirm diagnosis and extent of bleeding, and initiate aggressive blood pressure control with repeated dosing or continuous IV infusion of antihypertensives while monitoring every 15 minutes until stabilized. 1

Immediate Assessment and Stabilization

Neurological Evaluation

• Perform NIHSS on awake or drowsy patients, or Glasgow Coma Scale on obtunded patients immediately upon presentation, as baseline severity strongly predicts outcomes 1
• Repeat validated neurological assessments (such as CNS score) at least hourly for the first 24 hours, adjusting frequency based on patient stability 1
• Assess for clinical signs of increased intracranial pressure at each evaluation 1

Critical Pitfall: 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" on CT angiography), early presentation (<3 hours), anticoagulation use, and larger initial hematoma volume 1

Vital Signs Monitoring

• Assess blood pressure on initial arrival and every 15 minutes thereafter until stabilized 1
• Blood pressure targets require aggressive repeated dosing or continuous intravenous infusion of antihypertensive medications 1
• Monitor vital signs, mental status, and neurological deficits continuously to determine severity 1

Diagnostic Imaging Protocol

• Perform CT or MRI immediately to confirm diagnosis, location, and extent of hemorrhage 1
• Obtain CT angiography, MR angiography, or catheter angiography for most patients to exclude underlying structural lesions such as aneurysms or arteriovenous malformations 1

Coagulopathy Assessment and Reversal

Laboratory Evaluation

• Evaluate 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
• Obtain detailed medication history, particularly regarding anticoagulant and antiplatelet therapy 1

Pharmacologic Management

• Consider tranexamic acid 10-15 mg/kg followed by continuous infusion of 1-5 mg/kg/hour in bleeding patients 2
• Implement early measures to reduce heat loss and actively warm hypothermic patients to achieve and maintain normothermia 2

Fluid Resuscitation Strategy

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

Important Caveat: This restrictive blood pressure target applies only to patients without brain injury. In hemorrhagic stroke, blood pressure management requires more nuanced approach with careful monitoring and aggressive control to prevent hematoma expansion while maintaining cerebral perfusion.

Respiratory Management

• Optimize respiratory effort and maintain adequate oxygenation 1
• Apply initial normoventilation if there are no signs of imminent cerebral herniation 1

Avoid hyperventilation unless signs of imminent herniation are present, as excessive ventilation can worsen outcomes.

Surgical Considerations

• There is no compelling evidence that surgical evacuation of supratentorial intraparenchymal hematoma is beneficial in most cases 1
• Hematoma evacuation may alleviate impending brain herniation in selected individuals with large hematomas causing mass effect 1
• Damage-control surgery should be performed in severely injured patients presenting with hemorrhagic shock, signs of ongoing bleeding, coagulopathy, or hypothermia 2

Ongoing Monitoring Requirements

• Continue neurological assessments hourly for the first 24 hours 1
• Monitor for signs of rebleeding, increased intracranial pressure, and neurological deterioration 1
• Assess for development of complications including seizures and cerebral edema 1
• Apply early mechanical thromboprophylaxis with intermittent pneumatic compression while the patient is immobile and has bleeding risk 2