What is the treatment for a cerebral vascular accident (CVA)?

Treatment for Cerebrovascular Accident (CVA)

Intravenous tissue plasminogen activator (IV tPA) should be offered to selected patients with acute ischemic stroke within 3 hours of symptom onset at institutions where systems are in place to safely administer the medication. 1

Acute Ischemic Stroke Management

Initial Assessment and Time-Critical Interventions

• Immediate neuroimaging (CT or MRI) to distinguish between ischemic and hemorrhagic stroke
• Establish time of symptom onset (critical for treatment decisions)
• Assess stroke severity using standardized scales (e.g., National Institutes of Health Stroke Scale)
• Monitor vital signs with special attention to blood pressure management

Thrombolytic Therapy

• IV tPA (alteplase) is the cornerstone of acute ischemic stroke treatment
• Dosage: 0.9 mg/kg (maximum 90 mg) with 10% given as bolus and remainder over 60 minutes 1
• Time window:
  • 0-3 hours: Level B recommendation for improved functional outcomes 1
  • 3-4.5 hours: May be considered in selected patients 1
• Contraindications include:
  • Recent intracranial hemorrhage
  • Major surgery within 14 days
  • Gastrointestinal or urinary tract hemorrhage within 21 days
  • Arterial puncture at a non-compressible site within 7 days
  • Elevated blood pressure (>185/110 mmHg) despite treatment
  • Blood glucose <50 mg/dL or >400 mg/dL

Mechanical Thrombectomy

• Consider for patients with large vessel occlusions in the anterior circulation
• Can be performed up to 24 hours after symptom onset in selected patients 1
• Particularly beneficial when IV tPA is contraindicated or insufficient

Antiplatelet Therapy

• Aspirin (325 mg) should be administered within 24-48 hours of stroke onset if thrombolytic therapy is not given
• Delay aspirin for 24 hours if IV tPA is administered 1

Hemorrhagic Stroke Management

Intracerebral Hemorrhage

• Aggressive blood pressure control
• Reversal of anticoagulation if applicable
• Neurosurgical evaluation for potential hematoma evacuation in selected cases

Subarachnoid Hemorrhage

• Neurosurgical consultation for aneurysm management (clipping or coiling)
• Nimodipine to prevent vasospasm
• Careful blood pressure management

Post-Acute Care and Secondary Prevention

Hospital Management

• Admission to a specialized stroke unit improves outcomes
• Early mobilization and rehabilitation assessment
• Prevention of complications (DVT, pneumonia, pressure ulcers)

Secondary Prevention

• Antiplatelet therapy (aspirin, clopidogrel, or combination therapy)
• Anticoagulation for atrial fibrillation (when appropriate)
• Statin therapy
• Blood pressure control
• Lifestyle modifications (smoking cessation, diet, exercise)
• Carotid revascularization for significant stenosis if indicated

Special Considerations

Pediatric Stroke

• Different etiologies than adult stroke
• For children with extracranial cervicocephalic arterial dissection (CCAD), it is reasonable to begin either unfractionated heparin or low molecular weight heparin as a bridge to oral anticoagulation 1
• Anticoagulation typically continued for 3-6 months 1

Transfer Considerations

• Patients requiring specialized interventions should be transferred to a stroke center without delay
• Treatment should not be delayed for transfer when IV tPA can be administered at the initial facility 1

Common Pitfalls and Caveats

1. Time is brain - Delays in treatment significantly impact outcomes. Door-to-needle time should be minimized.

2. Risk of symptomatic intracerebral hemorrhage - The increased risk of bleeding must be considered when deciding to administer IV tPA. This risk increases with time from symptom onset 1.

3. Misdiagnosis - Stroke mimics (seizure, migraine, hypoglycemia) must be ruled out before thrombolytic therapy.

4. Incomplete history - Failure to identify contraindications to thrombolysis can lead to adverse outcomes.

5. Inadequate blood pressure control - Both hypertension and hypotension can worsen outcomes in acute stroke.

The Modified Rankin Scale is commonly used to assess functional outcomes after stroke, with scores ranging from 0 (no symptoms) to 6 (death). The goal of acute stroke treatment is to achieve excellent functional outcomes (mRS 0-1) by restoring cerebral blood flow as quickly as possible 1.