Management of Hemorrhagic Cerebrovascular Accident (CVA)

Initial Stabilization and Assessment

Immediate neuroimaging with CT or MRI is essential to confirm hemorrhagic stroke and identify underlying vascular abnormalities in patients with suspected cerebrovascular accident, according to the American Heart Association 3, 2
Control systemic hypertension with the goal of achieving a systolic blood pressure of 130-150 mmHg in patients with intracranial hemorrhage, as recommended by the American College of Cardiology 1
Avoid very intense and rapid blood pressure lowering below the optimal range as it can be harmful in the acute phase, with a strength of evidence level of high, according to the American Heart Association 1

Immediate reversal of ongoing anticoagulant treatment with dedicated reversal agents is recommended in patients with intracranial hemorrhage, with a high level of evidence, according to the American College of Cardiology 1
Tranexamic acid should be administered to patients with bleeding or at risk of significant bleeding as soon as possible, at a loading dose of 1g over 10 minutes, followed by infusion of 1g over 8 hours, as recommended by the Critical Care Society 4

Decompressive hemicraniectomy may be considered in patients with severe mass effect or neurological deterioration despite medical treatment, with a moderate level of evidence, according to the Neurosurgery Society 5, 6
Surgical intervention is most beneficial for hemorrhages in the cerebellum and for individuals with large lesions in the cerebral hemisphere causing impending brain herniation, as recommended by the American Heart Association 2

Monitor for vasospasm in subarachnoid hemorrhage cases using transcranial Doppler and clinical assessment, with a high level of evidence, according to the American Heart Association 7

After stabilization, admission to a stroke unit with a multidisciplinary approach to care is essential to reduce disability and mortality, with a high level of evidence, according to the American College of Cardiology 1
For patients with cavernous malformations causing hemorrhage, the risk of recurrent bleeding is approximately 4.5% per year, with deeper lesions having higher risk, as reported by the Stroke Society 3

Avoid normalizing blood pressure too rapidly during active hemorrhage as this may compromise cerebral perfusion, with a moderate level of evidence, according to the Anaesthesia Society 9