What is the cornerstone treatment for ischemic Cerebrovascular Accident (CVA)?

From the Guidelines

The cornerstone treatment for ischemic cerebrovascular accident (CVA) is rapid reperfusion therapy, primarily through intravenous recombinant tissue plasminogen activator (IV r-tPA, alteplase) administered within 4.5 hours of symptom onset. This approach is supported by the most recent and highest quality study, which emphasizes the importance of timely restoration of blood flow in ischemic stroke patients to reduce long-term morbidity 1. The standard dose of IV r-tPA is 0.9 mg/kg (maximum 90 mg), with 10% given as an initial bolus and the remainder infused over 60 minutes.

Key Considerations

• For eligible patients presenting within 24 hours with large vessel occlusion, mechanical thrombectomy may be performed, often in combination with IV thrombolysis 1.
• Time is critical in stroke management, as "time is brain" - approximately 1.9 million neurons die each minute during an untreated stroke.
• Beyond the acute phase, secondary prevention includes antiplatelet therapy (typically aspirin 81-325 mg daily, clopidogrel 75 mg daily, or combination therapy depending on stroke etiology), statins, blood pressure management, and risk factor modification.
• Patients should also receive early rehabilitation services to improve functional outcomes.

Evidence-Based Recommendations

The effectiveness of reperfusion therapy stems from its ability to restore blood flow to ischemic but potentially viable brain tissue in the penumbra surrounding the infarct core, limiting the final extent of brain damage and improving functional outcomes 1. The 2020 study published in the Journal of the American College of Cardiology emphasizes the importance of rapid patient transfer, diagnosis, and treatment, and recommends a combined endovascular therapy approach using stent-retrievers and aspiration to achieve fast first-pass complete reperfusion 1.

From the Research

Cornerstone Treatment for Ischemic CVA

The cornerstone treatment for ischemic Cerebrovascular Accident (CVA) involves several approaches, including:

• Intravenous thrombolysis with tissue-plasminogen activator (tPA) as the only approved systemic reperfusion therapy suitable for most patients presenting timely with acute ischemic stroke 2
• Mechanical thrombectomy (MT) as the standard-of-care treatment for acute ischemic stroke (AIS) of the anterior circulation, which may be performed irrespective of intravenous tissue plasminogen activator (IV-tPA) eligibility prior to the procedure 3
• Intra-arterial alteplase as an adjunct treatment after thrombectomy to improve functional outcomes in patients with large vessel occlusion acute ischemic stroke 4

Treatment Considerations

When considering treatment for ischemic CVA, the following factors should be taken into account:

• Pretreatment with anti-thrombotic agents, such as aspirin or anticoagulants, which can increase the bleeding risk of thrombolysis or thrombectomy 5
• The use of low-dose aspirin prior to stroke, which may be associated with improved functional outcomes and reduced mortality in patients undergoing mechanical thrombectomy for distal medium vessel occlusion ischemic stroke 6
• The potential benefits and risks of combining different treatment approaches, such as IV-tPA and MT, or using adjunct treatments like intra-arterial alteplase 3, 4

Key Findings

Key findings from the studies include:

• IV-tPA remains the only approved systemic reperfusion therapy suitable for most patients presenting timely with acute ischemic stroke 2
• MT may improve recanalization rates compared to IV-tPA alone in tPA-eligible patients being treated for AIS, but a corresponding improvement in functional and safety outcomes was not present in one review 3
• Intra-arterial alteplase may improve functional outcomes in patients with large vessel occlusion acute ischemic stroke, but further studies are needed to confirm these findings 4
• Pre-stroke low-dose aspirin may be associated with improved functional outcomes and reduced mortality in patients undergoing MT for distal medium vessel occlusion ischemic stroke, without a significant increase in symptomatic intracerebral hemorrhage 6