What are the treatment guidelines for ischemic Cerebrovascular Accident (CVA)?

Treatment Guidelines for Ischemic Stroke

Rapid administration of intravenous recombinant tissue-type plasminogen activator (rtPA) to appropriate patients within 4.5 hours of symptom onset, followed by endovascular thrombectomy for eligible patients with large vessel occlusions, is the cornerstone of acute ischemic stroke management. 1

Initial Assessment and Management

Immediate Evaluation

• Perform rapid neurological assessment using NIH Stroke Scale (NIHSS)
• Obtain non-contrast CT scan to rule out hemorrhagic stroke
• Consider CT angiography from arch-to-vertex for patients potentially eligible for endovascular treatment 2
• Establish time of symptom onset (critical for treatment decisions)

Blood Pressure Management

• For patients eligible for thrombolysis:
  • Reduce BP to <185/110 mmHg before rtPA administration
  • Maintain BP <180/105 mmHg for 24 hours after treatment 2
• For patients not receiving thrombolysis:
  • Avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic BP >120 mmHg
  • If treatment needed, reduce BP by only 10-15% 2

Primary Reperfusion Strategies

Intravenous Thrombolysis

• rtPA (Alteplase) 0.9 mg/kg (maximum 90 mg):
  • 10% as bolus over 1 minute
  • Remainder over 60 minutes 1
• Time windows:
  • Standard window: within 3 hours of symptom onset (Class I, Level of Evidence A) 1
  • Extended window: 3-4.5 hours for selected patients 1

rtPA Administration Protocol 1

1. Admit patient to intensive care or stroke unit for monitoring
2. Perform neurological assessments every 15 minutes during infusion, every 30 minutes for 6 hours, then hourly until 24 hours
3. Monitor BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly until 24 hours
4. If severe headache, acute hypertension, nausea, or vomiting develops, stop infusion and obtain emergency CT
5. Delay placement of nasogastric tubes, indwelling catheters, or intra-arterial lines
6. Obtain follow-up CT at 24 hours before starting anticoagulants or antiplatelet agents

Endovascular Treatment

• Indicated for patients with large vessel occlusions (internal carotid artery or proximal middle cerebral artery) 1
• Time window: within 6 hours of symptom onset (Class I, Level of Evidence A) 1
• Do not delay IV rtPA to pursue endovascular therapy - patients eligible for IV rtPA should receive it even if endovascular treatment is being considered 1
• Stent retrievers (Solitaire FR, Trevo) are preferred over coil retrievers (Merci) (Class I, Level of Evidence A) 1
• Technical goal: achieve TICI grade 2b/3 angiographic result 1

Patient Selection for Endovascular Therapy

• Prestroke modified Rankin Scale score of 0-1
• Causative occlusion of internal carotid artery or proximal MCA (M1)
• Age ≥18 years
• NIHSS score ≥6
• ASPECTS ≥6 1

Post-Acute Management

Antithrombotic Therapy

• Administer aspirin (325 mg initially, then 81-325 mg daily) within 24-48 hours after stroke onset 1, 2
• For patients treated with IV thrombolysis, delay aspirin administration until >24 hours 1
• Consider short-term dual antiplatelet therapy (aspirin plus clopidogrel) for 21-30 days for minor stroke or high-risk TIA 2

Monitoring and Supportive Care

• Admit to a dedicated stroke unit or ICU 1
• Perform cardiac monitoring for at least 24 hours to detect atrial fibrillation 1, 2
• Implement DVT prophylaxis with intermittent pneumatic compression devices for patients with limited mobility 1
• Monitor body temperature and treat fever (>38°C) 1
• Encourage gradual early mobilization 1

Systems of Stroke Care

• Transport patients rapidly to the closest certified primary stroke center or comprehensive stroke center 1
• Regional systems of stroke care should include:
  • Healthcare facilities that provide initial emergency care including IV rtPA
  • Centers capable of performing endovascular treatment with comprehensive periprocedural care 1

Common Pitfalls and Caveats

1. Delayed treatment: Door-to-needle time should be minimized as earlier treatments are associated with better outcomes. Studies show that implementation of quality improvement initiatives can significantly reduce door-to-needle times and improve clinical outcomes 3.

2. Inappropriate patient selection: Carefully review contraindications for rtPA before administration to minimize bleeding complications.

3. Inadequate blood pressure control: Failure to control BP before, during, and after thrombolysis increases the risk of intracranial hemorrhage.

4. Waiting for clinical improvement after IV rtPA before pursuing endovascular therapy: This is not recommended and can lead to delays in reperfusion 1.

5. Failure to recognize large vessel occlusion: Early identification through appropriate imaging is critical for timely endovascular intervention.

The evidence strongly supports that reducing time to reperfusion is critical for improving outcomes in acute ischemic stroke. The 2015 AHA/ASA guidelines represent a significant advancement in stroke care by incorporating endovascular therapy as a standard treatment option for eligible patients with large vessel occlusions, based on multiple positive clinical trials 1.