What are the current guidelines for managing a patient with hemorrhagic cerebrovascular accident (CVA)?

Management of Hemorrhagic Cerebrovascular Accident (CVA)

Patients with hemorrhagic stroke require immediate medical emergency treatment with rapid blood pressure control to systolic 140 mmHg (if presenting between 150-220 mmHg), urgent reversal of any anticoagulation, neurosurgical consultation, and intensive care unit monitoring with specialized stroke unit care. 1

Immediate Assessment and Stabilization

• Treat as a medical emergency with immediate evaluation by physicians experienced in hyperacute stroke management 1
• Perform rapid ABC assessment (airway, breathing, circulation) upon arrival 1
• Complete neurological examination using NIHSS to quantify stroke severity and guide treatment decisions 1
• Obtain non-contrast CT head within 30 minutes of hospital admission to confirm diagnosis, location, and extent of hemorrhage 1
• Urgent blood work must include complete blood count, coagulation status (INR, aPTT), and glucose 1
• Obtain detailed medication history, specifically regarding anticoagulant and antiplatelet therapy 1

Blood Pressure Management

For patients with systolic BP 150-220 mmHg without contraindications, acutely lower systolic BP to 140 mmHg—this is safe and improves functional outcomes 1. This represents the most recent high-quality evidence for BP targets in hemorrhagic stroke.

• Assess BP on initial arrival and every 15 minutes until stabilized 1
• Avoid antihypertensive agents that induce cerebral vasodilation (such as sodium nitroprusside) in patients with markedly elevated intracranial pressure 1
• Nicardipine is superior to labetalol for achieving and maintaining goal BP, with faster response time and fewer treatment failures 1
• Strictly avoid systolic BP <110 mmHg 2

Reversal of Coagulopathy

Anticoagulation must be discontinued immediately and reversed as soon as possible 2:

• For warfarin (INR ≥2.0): Administer 4-factor prothrombin complex concentrate (4F-PCC) over fresh frozen plasma, plus intravenous vitamin K to prevent re-emergence of anticoagulation 2
• Use FFP or 3F-PCC only when 4F-PCC is unavailable 2
• For heparin-related ICH: Administer protamine sulfate 2
• For direct oral anticoagulants: Use idarucizumab for dabigatran reversal; use andexanet alpha or 4F-PCC for factor Xa inhibitor reversal 2
• Patients with severe thrombocytopenia should receive platelet transfusion 1

Advanced Vascular Imaging

Obtain vascular imaging (CTA, MRA, or catheter angiography) to exclude underlying vascular lesions 1:

• Mandatory for lobar ICH in patients <70 years 2
• Mandatory for deep/posterior fossa ICH in patients <45 years 2
• Mandatory for deep/posterior fossa ICH in patients 45-70 years without hypertension history 2
• For spontaneous intraventricular hemorrhage without parenchymal hemorrhage, catheter angiography is required to exclude vascular anomaly 2

Monitoring and Care Setting

• Initial management must occur in ICU or dedicated stroke unit with physician and nursing neuroscience expertise 1
• Maintain nurse-patient ratio of 1:2 for first 24 hours, then 1:4 if stable 1
• Perform validated neurological scale assessment at baseline and repeat at least hourly for first 24 hours 1
• Initiate continuous cardiac monitoring for 24-72 hours to detect atrial fibrillation and arrhythmias 3

Management of Increased Intracranial Pressure

• Elevate head of bed 20-30 degrees to facilitate venous drainage 1
• Treat exacerbating factors: hypoxia, hypercarbia, hyperthermia 1
• For deteriorating patients with increased ICP: Consider osmotherapy (mannitol 0.25-0.5 g/kg IV over 20 minutes every 6 hours, maximum 2 g/kg) 1
• Hyperventilation can be used as temporizing measure for herniation syndromes 1
• Corticosteroids are NOT recommended for cerebral edema management 1
• For IVH with hydrocephalus causing decreased consciousness: External ventricular drainage is mandatory 2
• External ventricular drainage with intraventricular fibrinolysis promotes hematoma clearance, decreases mortality, and improves functional outcomes 1

Neurosurgical Intervention

Obtain prompt neurosurgical consultation for evaluation of potential surgical interventions 1:

• Cerebellar hemorrhage with neurological deterioration, brainstem compression, or hydrocephalus requires immediate surgical removal 1
• Consider early surgery for patients with Glasgow Coma Scale 9-12 1
• Surgical decompression recommended for large cerebellar infarctions causing brainstem compression and hydrocephalus 1

Seizure Management

• Treat new-onset seizures occurring within 24 hours with short-acting medications (e.g., lorazepam IV) if not self-limited 1
• Do NOT treat single, self-limiting seizures with long-term anticonvulsants 1
• Recurrent seizures should be treated as with any acute neurological condition 1
• Prophylactic anticonvulsants are NOT recommended for patients without seizures 1

Prevention of Complications

• Implement intermittent pneumatic compression for VTE prevention beginning day of admission 1
• Consider pharmacological VTE prophylaxis with UFH or LMWH after documenting hemorrhage stability on CT, typically 24-48 hours after ICH onset 1
• Do NOT use graduated compression stockings—they are less effective than intermittent pneumatic compression 1
• Perform formal dysphagia screening before initiating oral intake to reduce pneumonia risk 1

Fluid Management

• Avoid hypo-osmolar fluids (such as 5% dextrose in water) as they worsen cerebral edema 1
• Use isotonic saline 0.9% for fluid resuscitation 2
• Mild fluid restriction is recommended to help manage brain edema 1

Critical Pitfalls to Avoid

• Early deterioration is common: Over 20% of patients experience GCS decrease of ≥2 points between prehospital and ED evaluation 1
• Hematoma expansion occurs in 30-40% of patients within first hours and predicts poor outcome; risk factors include contrast extravasation ("spot sign"), early presentation, anticoagulant use, and large initial volume 1
• Do NOT delay imaging or treatment for diagnostic tests 1
• Hypotension must be corrected before transfer—persistent hypotension adversely affects neurological outcome 2
• For polytrauma patients with hemorrhagic brain injury, maintain SBP >100 mmHg or MAP >80 mmHg during interventions 2