What is the management and treatment for a patient experiencing a Cerebrovascular Accident (CVA)?

Management and Treatment of Cerebrovascular Accident (CVA)

Immediate recognition and rapid treatment of stroke is essential for reducing mortality and improving functional outcomes. Treatment should follow a time-sensitive protocol with specific interventions based on stroke type and time from symptom onset.

Initial Assessment and Management

• Recognize early warning signs: Sudden weakness/numbness of face/arm/leg, confusion, speech difficulties, vision problems, walking difficulties, dizziness, balance issues, or severe headache 1
• Urgent imaging: CT or MRI to differentiate between ischemic and hemorrhagic stroke 2
• Time is brain: Document symptom onset time precisely as it determines treatment options

Acute Management by Stroke Type

Ischemic Stroke

1. Thrombolytic therapy:

   • Administer recombinant tissue plasminogen activator (rtPA) at 0.9 mg/kg (maximum 90 mg) within 3 hours of symptom onset 1
   • Blood pressure must be <185/110 mmHg before, during, and after rtPA treatment 1

2. Endovascular thrombectomy:

   • Consider for large vessel occlusions identified on CT/MRI angiography 1
   • Particularly important for basilar artery occlusions presenting with ataxia, cranial nerve deficits, visual field loss, dizziness, or incoordination 1

3. Antiplatelet therapy:

   • Administer aspirin within 24-48 hours after stroke onset 2
   • For those treated with IV thrombolysis, delay aspirin administration until >24 hours 2

Hemorrhagic Stroke (Intracerebral Hemorrhage)

1. Blood pressure management:

   • For patients presenting within 6 hours of symptom onset, acutely lower systolic BP to target of 140 mmHg (strictly avoiding SBP <110 mmHg) 2

2. Anticoagulation reversal (if applicable):

   • Discontinue anticoagulation immediately 2
   • For VKA-associated ICH with INR ≥2.0, administer 4-factor prothrombin complex concentrate (PCC) over fresh-frozen plasma 2
   • For dabigatran reversal, use idarucizumab; for factor Xa inhibitors, use andexanet alpha or 4F-PCC 2
   • Administer IV vitamin K shortly after PCC or FFP 2
   • For heparin-related ICH, administer protamine sulfate 2

3. Management of complications:

   • For IVH with hydrocephalus causing decreased consciousness, external ventricular drainage is recommended 2

Hospital Care

• Admission to specialized unit: Patients should be admitted to a stroke unit or intensive care unit if critically ill 2
• Cardiac monitoring: Monitor for at least the first 24 hours to screen for atrial fibrillation and other arrhythmias 2
• Temperature management: Monitor body temperature and treat fever (>38°C); investigate and treat sources of fever 2
• Seizure management: Antiseizure medications only for documented secondary seizures 2
• Mobilization: Encourage gradual early mobilization; use intermittent pneumatic compression devices for patients with limited mobility 2

Cognitive Rehabilitation

• Cognitive assessment and retraining for:

  • Attention deficits
  • Visual neglect
  • Memory deficits
  • Executive function and problem-solving difficulties 2

• Memory strategies: Training to develop compensatory strategies for memory deficits in patients with mild short-term memory impairments 2

Rehabilitation

• Early initiation: Begin rehabilitation 24-48 hours after stroke onset 1
• Multidisciplinary approach: Care by a team with regular meetings (at least weekly) improves functional outcomes and reduces mortality regardless of age, sex, initial severity, and stroke type 1
• Early supported discharge: Consider for appropriate patients to increase likelihood of living at home at 3 months 1

Prevention of Complications

• DVT prophylaxis: Use thigh-high intermittent pneumatic compression devices for patients with limited mobility 2
• Blood pressure control: Maintain BP below 180/105 mmHg for at least 24 hours after acute reperfusion treatment 2
• Massive stroke management: Patients with massive cerebral/cerebellar infarction or hemorrhage should be rapidly transferred to centers with neurosurgical expertise 2

Common Pitfalls to Avoid

1. Delayed recognition: Failure to recognize stroke symptoms leads to treatment delays and worse outcomes
2. Inappropriate BP management: Overly aggressive BP reduction can worsen ischemic areas; inadequate control increases hemorrhage risk
3. Missing large vessel occlusions: Failure to perform vascular imaging may miss candidates for endovascular therapy
4. Neglecting rehabilitation: Delayed initiation of rehabilitation reduces functional recovery potential
5. Overlooking anticoagulation reversal: Failure to rapidly reverse anticoagulation in hemorrhagic stroke increases mortality

The evidence strongly supports a coordinated, protocol-driven approach to stroke management with emphasis on rapid assessment, appropriate acute interventions based on stroke type, and early rehabilitation to maximize functional outcomes and reduce mortality.