What are the guidelines for managing cerebrovascular accident (CVA) or stroke?

Guidelines for Management of Cerebrovascular Accident (CVA)

Patients with acute ischemic stroke should be evaluated and treated immediately as a life-threatening emergency, with admission to a specialized stroke unit or intensive care unit for comprehensive care.1

Initial Assessment and Management

Prehospital Care

• Rapid evaluation, early stabilization, and transport to a stroke-ready hospital
• Maintain oxygen saturation >94% with supplemental oxygen if needed
• For hypotensive patients: place head of stretcher flat and administer isotonic saline
• Check blood glucose (treat if <60 mg/dL)
• Establish IV access during transport 1

Emergency Department Evaluation

• Urgent evaluation to determine if ischemic stroke is the likely cause
• Assess eligibility for intravenous rtPA (time window <3 hours from symptom onset)
• Cardiac monitoring to detect atrial fibrillation and life-threatening arrhythmias 1

Acute Reperfusion Therapy

• Intravenous rtPA (0.9 mg/kg; maximum 90 mg) is strongly recommended for carefully selected patients within 3 hours of stroke onset 1
• Blood pressure should be maintained below 185/105 mmHg for at least 24 hours after reperfusion treatment 1
• Intra-arterial thrombolysis may be considered for selected patients beyond the 3-hour window, though patient selection criteria are not fully established 1

Hospital Management

Blood Pressure Management

• Cautious approach to hypertension treatment
• Avoid antihypertensive agents unless systolic BP >220 mmHg or diastolic BP >120 mmHg
• Use short-acting agents with minimal effect on cerebral blood vessels
• Avoid sublingual nifedipine and other agents causing precipitous BP reduction 1

Antiplatelet Therapy

• Administer aspirin within 24-48 hours after stroke onset
• For patients treated with IV thrombolysis, delay aspirin administration until >24 hours
• Use alternative antiplatelet medication for patients with aspirin allergy 1

Prevention of Complications

DVT/PE Prevention

• Early mobilization and adequate hydration
• Antiplatelet therapy for ischemic stroke patients
• Consider low molecular weight heparin or heparin in prophylactic doses for high-risk patients
• Consider thigh-length antithrombotic stockings for selected patients 1

Temperature Management

• Monitor body temperature and treat fever (temperature >38°C)
• Investigate and treat sources of fever
• Use antipyretic therapy (regular paracetamol and/or physical cooling measures) 1

Swallowing and Nutrition

• Assess swallowing ability before allowing oral intake
• Risk factors for aspiration: brain stem infarctions, multiple strokes, large hemispheric lesions, depressed consciousness
• Consider nasogastric or nasoduodenal tube for patients who cannot swallow safely 1

Management of Specific Complications

Cerebral Edema and Increased Intracranial Pressure

• Patients with large territorial infarctions are at high risk for brain edema and increased ICP
• Monitor for signs of neurological worsening during first days after stroke
• Consider early transfer to institutions with neurosurgical expertise 1

Surgical Management

• Decompressive surgical evacuation of space-occupying cerebellar infarction is effective in preventing herniation and brain stem compression 1
• Decompressive surgery for malignant edema of cerebral hemisphere is effective and potentially lifesaving (particularly for patients 18-60 years with surgery within 48 hours of symptom onset) 1
• Corticosteroids are NOT recommended for management of brain edema and raised ICP 1

Seizures

• Antiseizure medications indicated only for documented secondary seizures 1
• Prophylactic use of anticonvulsants is not recommended 1

Rehabilitation Considerations

Mood Disorders

• Assess patients with suspected altered mood using standardized scales
• Consider antidepressants for emotional lability
• Treat depression or anxiety with antidepressants and/or psychological interventions 1

Mobility and Pressure Care

• Encourage gradual early mobilization
• Complete pressure care risk assessment for patients unable to mobilize independently
• Provide pressure-relieving mattress for high-risk patients 1

Special Considerations

Massive Stroke

• Management decisions should involve shared decision-making with patient (when possible) and family
• Consider prognosis for functional recovery
• Rapidly transfer patients with massive cerebral/cerebellar infarction or hemorrhage to centers with neurosurgical expertise if condition is deemed survivable 1

Common Pitfalls to Avoid

• Delaying evaluation and treatment (stroke is a time-sensitive emergency)
• Aggressive blood pressure reduction in acute phase
• Using corticosteroids for cerebral edema
• Prophylactic anticonvulsants
• Allowing oral intake without swallowing assessment
• Delaying neurosurgical consultation for patients with large territorial infarcts at risk for malignant edema

By following these evidence-based guidelines, healthcare providers can optimize outcomes for patients with cerebrovascular accidents, reducing mortality and improving quality of life.