What is the immediate treatment for a patient presenting with hemorrhagic cerebrovascular accident (CVA)?

Immediate Treatment of Hemorrhagic Cerebrovascular Accident

Patients with intracerebral hemorrhage must be treated as a medical emergency with immediate CT imaging, aggressive blood pressure control targeting systolic BP ≤140 mmHg (strictly avoiding <110 mmHg) within 6 hours of symptom onset, and urgent reversal of any anticoagulation. 1

Initial Assessment and Stabilization

Neurological Evaluation

• Conduct NIHSS on awake/drowsy patients or Glasgow Coma Scale on obtunded patients immediately upon arrival to establish baseline severity, which strongly predicts outcomes 1, 2
• Assess for clinical signs of increased intracranial pressure including pupillary changes, altered consciousness, and focal neurological deficits 1, 2
• Repeat validated neurological assessments (CNS score) at least hourly for the first 24 hours, adjusting frequency based on patient stability 1, 2

Immediate Diagnostic Imaging

• Perform CT or MRI immediately to confirm diagnosis, location, and extent of hemorrhage 1, 2
• Obtain CT angiography, MR angiography, or catheter angiography to exclude underlying vascular lesions (aneurysm, arteriovenous malformation) in most patients 1, 2
• This is particularly critical for: lobar ICH in patients <70 years, deep/posterior fossa ICH in patients <45 years, or deep/posterior fossa ICH in patients 45-70 years without hypertension history 1

Blood Pressure Management

Acute BP Control Protocol

• Assess blood pressure on initial ED arrival and every 15 minutes until stabilized 1, 2
• Target systolic BP ≤140 mmHg in patients presenting within 6 hours of symptom onset to reduce hematoma expansion risk 1
• Strictly avoid systolic BP <110 mmHg as this may compromise cerebral perfusion 1
• Continue close BP monitoring every 30-60 minutes (or more frequently if above target) for at least 24-48 hours 1
• Achieving these targets often requires aggressive repeated dosing or continuous intravenous infusion of antihypertensive medications 1, 2

Coagulopathy Reversal

Immediate Laboratory Assessment

• Evaluate anticoagulant therapy history, measure platelet count, partial thromboplastin time (PTT), and INR immediately 1, 2
• Obtain detailed medication history focusing on anticoagulants and antiplatelet agents 1, 2

Anticoagulation Reversal Strategies

• For warfarin-associated ICH with INR ≥2.0: administer 4-factor prothrombin complex concentrate (4F-PCC) over fresh-frozen plasma 1
  • Use FFP or 3F-PCC only when 4F-PCC unavailable 1
  • Administer IV vitamin K shortly after PCC/FFP to prevent re-emergence of anticoagulation 1
• For heparin-related ICH: administer protamine sulfate 1
• For direct oral anticoagulant-associated ICH:
  • Dabigatran: use idarucizumab 1
  • Factor Xa inhibitors: use andexanet alpha or, if unavailable, 4F-PCC 1
• Discontinue all anticoagulation immediately upon diagnosis 1

Management of Increased Intracranial Pressure

Intraventricular Hemorrhage with Hydrocephalus

• Place external ventricular drainage for intraventricular hemorrhage with hydrocephalus contributing to decreased consciousness 1
• For spontaneous intraventricular hemorrhage without detectable parenchymal hemorrhage, perform catheter angiography to exclude vascular anomaly 1

Cerebral Herniation

• In cases of cerebral herniation awaiting or during emergency neurosurgery: use osmotherapy and/or temporary hypocapnia 1
• Maintain systolic BP >100 mmHg or MAP >80 mmHg during emergency neurosurgery 1

Neurosurgical Consultation

Indications for Urgent Neurosurgical Evaluation

• All salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation and intervention 1
• Patients at risk for intracranial hypertension (comatose with radiological signs) require ICP monitoring 1
• However, there is no compelling evidence that surgical evacuation of supratentorial intraparenchymal hematoma benefits most patients 2
• Hematoma evacuation may be considered to alleviate impending brain herniation in selected individuals 2

Supportive Care Measures

Respiratory Management

• Optimize respiratory effort and maintain adequate oxygenation 2
• Maintain arterial partial pressure of oxygen (PaO2) between 60-100 mmHg 1
• Maintain arterial partial pressure of carbon dioxide (PaCO2) between 35-40 mmHg 1
• Apply initial normoventilation unless signs of imminent cerebral herniation present 1

Transfusion Thresholds

• Transfuse red blood cells for hemoglobin <7 g/dL during emergency neurosurgery 1
• Higher thresholds may be appropriate for elderly patients or those with limited cardiovascular reserve 1

Platelet and Coagulation Management

• Maintain platelet count >50,000/mm³ for life-threatening hemorrhage 1
• Higher platelet values advisable for emergency neurosurgery including ICP probe insertion 1
• Maintain PT/aPTT <1.5 times normal control during emergency interventions 1

Critical Pitfalls and Monitoring

Hematoma Expansion Risk

• Recognize that 30-40% of patients experience hematoma expansion, a strong predictor of poor outcome 1
• Risk factors include: contrast extravasation on CTA ("spot sign"), early presentation, anticoagulation use, and larger initial hematoma volume 1

Ongoing Surveillance

• Continue neurological assessments hourly for first 24 hours 1, 2
• Monitor for signs of rebleeding, increased intracranial pressure, and neurological deterioration 2
• Assess for development of seizures and cerebral edema 2
• Administer antiseizure medications only for documented secondary seizures, not prophylactically 1

Temperature Management

• Monitor body temperature continuously 1
• Treat fever (temperature >38°C) and investigate/treat sources 1

Admission and Specialized Care

• Admit all ICH patients to a stroke unit or intensive care unit 1
• Cardiac monitoring recommended for at least first 24 hours to screen for arrhythmias 1