What are the guidelines for a post-hospitalization visit for a patient with a history of Cerebrovascular Accident (CVA) and dens fracture, to be seen by a Primary Care Physician (PCP)?

From the Guidelines

A post-hospitalization visit for a patient who has experienced both a cerebrovascular accident (CVA, or stroke) and a dens fracture should be scheduled with their primary care physician (PCP) within 7-14 days after discharge. This follow-up is crucial to monitor recovery progress, adjust medications, and coordinate rehabilitation services. The visit should include a comprehensive neurological assessment to evaluate stroke recovery, including motor function, speech, and cognitive abilities, as recommended by the Canadian Stroke Best Practice Recommendations 1. For the dens fracture (a fracture of the second cervical vertebra), the PCP should assess pain levels, neck mobility, and proper healing of the cervical spine, often in coordination with neurosurgery or orthopedic specialists, following the principles outlined in the EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture 1.

Medication management is essential, typically including:

• Antithrombotics such as aspirin (81-325mg daily) or clopidogrel (75mg daily) for secondary stroke prevention, as suggested by the National Stroke Association guidelines 1
• Appropriate pain management for the fracture
• Blood pressure control, often with medications like ACE inhibitors or ARBs, aiming for targets below 140/90 mmHg, as recommended by the European Guidelines on cardiovascular disease prevention in clinical practice 1

The PCP should also coordinate physical therapy, occupational therapy, and speech therapy as needed based on the patient's deficits, ensuring that patients receive a recommended three hours per day of direct task-specific therapy, five days a week, delivered by the interprofessional stroke team 1. Regular follow-up visits should be scheduled every 1-3 months initially, with frequency decreasing as the patient stabilizes. This comprehensive approach addresses both the neurological and orthopedic aspects of the patient's condition, reducing the risk of complications and optimizing functional recovery.

From the Research

Post Hospitalization Visit for CVA and Dens Fracture with PCP

• The treatment for dens fractures is unclear, but a staged treatment protocol has been established, which includes immobilization in a rigid collar for stable fractures, and posterior transarticular C1-C2 stabilization or direct anterior screw fixation for unstable fractures 2.
• For patients with a recent ischemic stroke, dual antiplatelet therapy with aspirin and clopidogrel may be recommended within 24 hours of symptom onset, and continued for 10-21 days 3.
• Clopidogrel monotherapy has been shown to be more effective than aspirin monotherapy in reducing the risk of major adverse cardiovascular and cerebrovascular events, recurrent stroke, and bleeding events in patients with recent ischemic stroke 4.
• Dual antiplatelet therapy with aspirin and clopidogrel has been shown to reduce the risk of recurrent stroke and major adverse cardiovascular events, but may increase the risk of moderate or severe bleeding compared to aspirin monotherapy 5.
• The efficacy and safety of clopidogrel and/or aspirin for ischemic stroke or transient ischemic attack have been evaluated in several systematic reviews and meta-analyses, which suggest that dual antiplatelet therapy may be more effective than monotherapy in reducing the risk of recurrent stroke, but may increase the risk of bleeding events 6.

Management of CVA and Dens Fracture

• The management of CVA (cerebrovascular accident) and dens fracture requires a comprehensive approach, including medical management, physical therapy, and possibly surgery.
• Patients with dens fracture may require immobilization in a rigid collar, and those with unstable fractures may require surgical stabilization.
• Patients with CVA may require antiplatelet therapy, such as aspirin or clopidogrel, to reduce the risk of recurrent stroke.

Follow-up Care

• Follow-up care for patients with CVA and dens fracture is crucial to monitor their condition and adjust treatment as needed.
• Patients should be followed up regularly with their primary care physician (PCP) to monitor their condition and adjust treatment as needed.
• Patients should also be educated on the importance of adhering to their treatment plan, including taking medications as prescribed and attending follow-up appointments.