What is the initial management for a patient presenting to the Emergency Department (ED) with a cerebrovascular accident (CVA)?

Initial Management of Cerebrovascular Accident (CVA) in the Emergency Department

The initial management of a patient presenting to the Emergency Department with a suspected cerebrovascular accident (CVA) requires immediate assessment and stabilization of airway, breathing, and circulation, followed by rapid neuroimaging within 25 minutes of arrival to distinguish between ischemic and hemorrhagic stroke. 1

Immediate Priorities (First 10 Minutes)

Assessment and Stabilization

• Airway, Breathing, Circulation (ABCs)
  • Ensure patent airway
  • Administer supplemental oxygen if oxygen saturation <94% 1
  • Establish IV access immediately 1

Rapid Neurological Evaluation

• Perform neurological screening assessment using validated tools:
  • National Institutes of Health Stroke Scale (NIHSS) for awake/drowsy patients
  • Glasgow Coma Scale (GCS) for obtunded or comatose patients 1
• Critical information to establish:
  • Exact time of symptom onset (when patient was last known to be normal) 1
  • Use creative questioning to establish time anchors (phone calls, TV programs) for unclear onset times 1

Initial Investigations (Immediate)

• Blood tests: 1
  • Complete blood count
  • Coagulation studies (PT/INR, PTT)
  • Blood glucose (treat hypoglycemia immediately if present)
  • Basic metabolic panel
• 12-lead ECG (does not take priority over CT scan) 1
• Activate stroke team/protocol immediately upon recognition 1

Neuroimaging (Within 25 Minutes)

• Non-contrast CT scan to distinguish between ischemic and hemorrhagic stroke 1, 2
• CT angiography (CTA) from aortic arch to vertex to identify large vessel occlusions 2
• For facilities without in-house imaging expertise, use FDA-approved teleradiology systems 1

Management Based on Stroke Type

For Ischemic Stroke

1. Blood pressure management:

   • If candidate for thrombolysis: maintain BP <185/110 mmHg 1
   • If BP >185/110 mmHg and patient eligible for thrombolysis:
     • Labetalol 10-20 mg IV over 1-2 minutes (may repeat once), or
     • Nicardipine IV 5 mg/hr, titrate up by 2.5 mg/hr every 5-15 minutes (maximum 15 mg/hr) 1

2. Reperfusion therapy assessment:

   • IV thrombolysis (alteplase) for eligible patients within 4.5 hours of symptom onset
     • Dose: 0.9 mg/kg (maximum 90 mg) 2
   • Endovascular thrombectomy for large vessel occlusion (can be considered up to 24 hours with evidence of salvageable brain tissue) 2

3. Antiplatelet therapy:

   • Aspirin 160-325 mg within 48 hours of stroke onset (after hemorrhage is ruled out) 2
   • Alternatives for patients with aspirin contraindications: clopidogrel (75 mg daily) or ticlopidine (250 mg twice daily) 2

For Hemorrhagic Stroke

1. Blood pressure assessment every 15 minutes until stabilized 1
2. Blood pressure management - targets may be challenging to achieve and require careful monitoring 1
3. Reversal of anticoagulation if applicable 1
4. Neurosurgical consultation for evaluation of potential surgical intervention 1

Ongoing Monitoring

• Cardiac monitoring for first 24 hours to detect atrial fibrillation and potentially life-threatening arrhythmias 1
• Neurological assessments using validated scales at least hourly for first 24 hours 1
• Close blood pressure monitoring (every 30-60 minutes) for at least first 24-48 hours 1

Common Pitfalls to Avoid

• Delayed recognition of stroke symptoms: Be aware that up to 35.7% of ischemic stroke patients may present with non-traditional symptoms 3
• Missing stroke mimics: Consider conditions such as hypoglycemia, seizures, migraines, and drug toxicity that can present with stroke-like symptoms 1
• Delaying imaging: Failure to obtain rapid neuroimaging is a common source of diagnostic error 3
• Overlooking posterior circulation strokes: Vertebral artery strokes may present with symptoms like dizziness, vertigo, diplopia, and ataxia rather than traditional stroke symptoms 2
• Inadequate blood pressure management: Inappropriate BP control can worsen outcomes in both ischemic and hemorrhagic stroke 1

By following this structured approach to the initial management of CVA in the Emergency Department, clinicians can optimize outcomes for stroke patients through rapid assessment, appropriate imaging, and timely intervention.