What is the management approach for cerebral vascular accident (CVA)?

Management of Cerebrovascular Accident (CVA)

The management of cerebrovascular accident requires immediate neuroimaging with CT or MRI to differentiate between hemorrhagic and ischemic stroke, followed by specific treatment protocols based on stroke type, with admission to a specialized stroke unit to reduce mortality and improve outcomes. 1

Initial Assessment and Stabilization

• Immediate neuroimaging with CT or MRI is essential to confirm stroke type (hemorrhagic vs. ischemic) and identify underlying vascular abnormalities 1
• Prehospital management should focus on ventilatory and cardiovascular support while transporting the patient to the closest facility prepared to care for acute stroke patients 2
• Emergency medical services should provide advance notice to the emergency department to initiate critical pathways and alert consulting services 2
• Admission to a stroke unit with specialized care is associated with a 14% reduction in the odds of death at 1 year and improved functional outcomes 2

Management of Ischemic Stroke

Acute Phase Treatment

• For eligible patients with ischemic stroke, intravenous alteplase should be administered within the approved time window (typically within 4.5 hours of symptom onset) 3
• Blood pressure management is critical, with targets varying based on whether thrombolytic therapy is administered 1
• For patients with large vessel occlusion, mechanical thrombectomy should be considered if within the appropriate time window 2

Management of Cerebral Edema in Ischemic Stroke

• In swollen supratentorial hemispheric ischemic stroke, decompressive craniectomy with dural expansion should be considered in patients who continue to deteriorate neurologically 2
• For swollen cerebellar stroke, suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically 2
• Ventriculostomy to relieve obstructive hydrocephalus after a cerebellar infarct should be accompanied by decompressive suboccipital craniectomy 2

Management of Hemorrhagic Stroke

• Control systemic hypertension with a goal of achieving systolic blood pressure of 130-150 mmHg 1
• Immediate reversal of anticoagulant treatment with dedicated reversal agents is recommended for patients on anticoagulation therapy 1
• Tranexamic acid should be administered to patients with active bleeding as soon as possible (loading dose of 1g over 10 minutes, followed by infusion of 1g over 8 hours) 1
• Surgical intervention is most beneficial for hemorrhages in the cerebellum and for large lesions in the cerebral hemisphere causing impending brain herniation 1

Management of Cerebral Venous Thrombosis (CVT)

• MRI with T2*-weighted imaging plus MRV is the preferred diagnostic method; CT/CTV can be used when MRI is not readily available 2
• Initiate anticoagulation (IV heparin or subcutaneous LMWH) if no major contraindications exist, even in the presence of hemorrhagic transformation 2
• Continue oral anticoagulation for 3-12 months or lifelong depending on the underlying etiology:
  • 3-6 months for transient reversible factors
  • Longer duration for high-risk thrombophilia or recurrent events 2
• Consider decompressive hemicraniectomy for patients with severe mass effect or neurological deterioration despite medical treatment 2
• Endovascular therapy may be considered in patients with contraindications to anticoagulation or failure of initial anticoagulant therapy 2

Special Considerations

• For arteriovenous malformations (AVMs), a multimodality approach is often necessary:
  • Surgical extirpation for Spetzler-Martin grade I and II lesions
  • Combined embolization followed by surgery for grade III lesions
  • Radiosurgery for small lesions in high-risk locations 2
• In sickle cell disease patients, specific risk factors for stroke include prior transient ischemic attack, low steady-state hemoglobin, recent acute chest syndrome, and elevated systolic blood pressure 4

Common Pitfalls and Considerations

• Misdiagnosis of CVA is common in the prehospital setting, with conditions like vertigo, electrolyte disturbances, seizures, and cardiovascular disorders frequently mistaken for stroke 5
• Avoid normalizing blood pressure too rapidly during active hemorrhage as this may compromise cerebral perfusion 1
• Intracranial hemorrhage that occurred as a consequence of cerebral venous thrombosis is not a contraindication for anticoagulation 2
• Despite extensive evaluation, approximately 30% of strokes in young adults have no identifiable etiological diagnosis 6

Post-Acute Care

• After stabilization, a multidisciplinary approach to rehabilitation is essential to reduce disability 1
• Follow-up imaging (CTV or MRV) at 3-6 months after diagnosis is reasonable to assess for recanalization in CVT patients 2
• Monitor for recurrent stroke risk factors and implement appropriate secondary prevention strategies based on stroke etiology 7