What is the initial management plan for a patient presenting with a cerebrovascular accident (CVA) in the hospital?

Initial Management Plan for Cerebrovascular Accident (CVA) in the Hospital

Patients presenting with suspected cerebrovascular accident (CVA) should be immediately admitted to a specialized stroke unit or intensive care unit if critically ill, with rapid neuroimaging, vascular assessment, and appropriate medical management initiated within the first hours of presentation to reduce morbidity and mortality.1

Immediate Assessment (First Hours)

Neuroimaging

• Brain imaging: Immediate CT or MRI to distinguish between ischemic stroke and intracerebral hemorrhage (ICH)1
  • CT is most widely available and fastest for initial assessment
  • MRI with diffusion-weighted imaging provides more detailed information if readily available

Vascular Imaging

• Non-invasive vascular imaging: CT angiography (CTA) or MR angiography (MRA) from aortic arch to vertex1
  • Should be performed simultaneously with initial brain imaging when possible
  • Identifies significant extracranial carotid stenosis requiring potential revascularization
  • Helps identify macrovascular causes in ICH patients

Laboratory Investigations

• Essential bloodwork:1
  • Complete blood count with platelets
  • Electrolytes and renal function (creatinine, eGFR)
  • Coagulation studies (INR, aPTT)
  • Blood glucose or hemoglobin A1C
  • Troponin
  • In patients >50 years: ESR and CRP to screen for giant cell arteritis

Cardiac Assessment

• 12-lead ECG: Immediate assessment to identify atrial fibrillation or evidence of structural heart disease1
• Cardiac monitoring: Continuous for at least the first 24 hours to detect arrhythmias1

Management Based on Stroke Type

For Ischemic Stroke

1. Blood pressure management:

   • Maintain BP below 180/105 mmHg for at least 24 hours after acute reperfusion treatment1
   • Avoid aggressive BP lowering as it may compromise cerebral perfusion2

2. Antiplatelet therapy:

   • Administer aspirin 160-300mg within 24-48 hours after stroke onset1, 2
   • Delay aspirin administration for >24 hours if thrombolytic therapy was given1
   • Consider dual antiplatelet therapy (clopidogrel plus aspirin) for high-risk TIA or minor stroke patients3

3. Reperfusion therapy assessment:

   • Evaluate eligibility for IV thrombolysis (generally within 4.5 hours of symptom onset)2
   • Consider endovascular thrombectomy for large vessel occlusions (up to 6-24 hours depending on imaging)4

For Intracerebral Hemorrhage (ICH)

1. Blood pressure control:

   • For spontaneous ICH with hypertension presenting within 6 hours: lower SBP to target of 140 mmHg (avoiding SBP <110 mmHg)1

2. Reversal of anticoagulation (if applicable):

   • Discontinue anticoagulation immediately1
   • For VKA-associated ICH with INR ≥2.0: administer 4-factor PCC over FFP, plus IV vitamin K1
   • For dabigatran: administer idarucizumab1
   • For factor Xa inhibitors: administer andexanet alpha or 4F-PCC if andexanet unavailable1
   • For heparin-related ICH: administer protamine sulfate1

3. Surgical evaluation:

   • For cerebellar hemorrhage with neurological deterioration, brainstem compression, or hydrocephalus: urgent surgical evacuation1
   • For IVH with hydrocephalus causing decreased consciousness: external ventricular drainage1

For Cerebral Venous Sinus Thrombosis (CVST)

1. Anticoagulation:

   • Start immediately after diagnosis, even if intracranial hemorrhage is present1
   • Use IV heparin or subcutaneous LMWH1

2. Exclude infections:

   • Investigate and treat possible causative infections1

General Care Measures (All Stroke Types)

1. Monitoring:

   • Serial neurological examinations to detect early deterioration1
   • For massive strokes: repeat head CT when appropriate to identify worsening brain swelling1

2. Fever management:

   • Monitor body temperature and treat fever (>38°C)1
   • Investigate and treat sources of fever1

3. Seizure management:

   • Administer antiseizure medications only for documented seizures1
   • Treat electrographic seizures found on EEG in patients with altered mental status1

4. DVT prophylaxis:

   • Encourage gradual early mobilization1
   • For patients with limited mobility: use thigh-high intermittent pneumatic compression devices1

5. Dysphagia screening:

   • Perform formal screening before initiating oral intake to reduce pneumonia risk1

6. Glucose management:

   • Monitor glucose and avoid both hyperglycemia and hypoglycemia1

Early Rehabilitation and Secondary Prevention

1. Early rehabilitation:

   • Initiate within 24-48 hours for stable patients2
   • Multidisciplinary approach including physical, occupational, and speech therapy1

2. Secondary prevention:

   • Blood pressure control for all stroke patients1
   • Statin therapy for appropriate patients2
   • Antiplatelet or anticoagulation therapy based on stroke etiology2

Common Pitfalls to Avoid

1. Delaying neuroimaging: Brain imaging should be performed immediately to distinguish between ischemic and hemorrhagic stroke, as management differs significantly1

2. Inappropriate blood pressure management: Overly aggressive BP lowering in ischemic stroke may worsen outcomes; conversely, failure to control BP in hemorrhagic stroke may increase hematoma expansion1

3. Missing dysphagia: Failure to screen for swallowing difficulties before oral intake increases risk of aspiration pneumonia1

4. Overlooking cardiac sources: Inadequate cardiac monitoring may miss paroxysmal atrial fibrillation or other cardiac sources of embolism1

5. Delayed mobilization: Prolonged immobilization increases risk of complications including DVT, pressure ulcers, and pneumonia1, 5