This patient should receive labetalol intravenously. He most likely has an intracerebral hemorrhage induced by hypertension. In patients with this type of hemorrhage and a systolic blood pressure greater than 180 mm Hg, acute blood pressure lowering is indicated. Hematoma expansion is a significant source of morbidity and mortality in intracerebral hemorrhage, particularly with extension into the ventricles, and commonly occurs within the first 3 hours after hemorrhage onset. Uncontrolled hypertension is a strong risk factor for hematoma expansion. In this patient, the blood pressure should be lowered to less than 160/90 mm Hg, according to American Heart Association guidelines. A recent clinical trial even reported that lowering blood pressure to less than 140/80 mm Hg was safe and led to a trend in improvement in neurologic outcomes. Labetalol is a fast-acting agent that can be titrated easily.

Intravenous nitroprusside can increase intracranial pressure and thus should be avoided in this patient with a likely intracerebral hemorrhage. The mechanism of action is thought to be related to an increase in cerebral blood volume from either a direct increase in venous volume or impaired venous drainage.

No evidence supports the use of platelet transfusion to improve outcomes in intracerebral hemorrhage or prevent hematoma expansion in patients taking antiplatelet agents. Associated risks of platelet transfusion include transfusion syndrome and volume overload.

Recombinant factor VIIa is inappropriate treatment for this patient. Studies have not shown a beneficial role of hemostatic agents in intracerebral hemorrhage without coagulopathy. In fact, a phase 3 trial that compared recombinant factor VIIa with placebo showed no improvement in neurologic outcomes but a significant increase in the rate of thrombotic complications.