What is the approach to comprehensive management of cerebrovascular accident (CVA) or stroke?

From the Guidelines

Comprehensive stroke management requires a multifaceted approach beginning with rapid recognition and treatment, prioritizing admission to a specialized stroke unit as soon as possible, ideally within 24 hours of hospital arrival 1. The approach to managing cerebrovascular accident (CVA) or stroke involves several key components.

Immediate Treatment

For acute ischemic stroke, intravenous alteplase (tPA) should be administered within 4.5 hours of symptom onset at a dose of 0.9 mg/kg (maximum 90 mg), with 10% given as a bolus and the remainder over 60 minutes. However, the most recent and highest quality study 1 does not specifically mention the time frame or dosage, but an older study 1 recommends intravenous administration of rtPA (0.9 mg/kg; maximum 90 mg) within 3 hours of onset of stroke.

Stroke Unit Care

Patients admitted to hospital with an acute stroke or TIA should be treated on an inpatient stroke unit as soon as possible. The core interdisciplinary team on the stroke unit should consist of healthcare professionals with stroke expertise, including physicians, nurses, occupational therapists, physiotherapists, speech-language pathologists, social workers, and clinical nutritionists 1.

Assessment and Management

The interdisciplinary team should assess patients within 48 hours of admission to hospital and formulate a management plan, using standardized, valid assessment tools to evaluate the patient’s stroke-related impairments and functional status 1.

Rehabilitation and Secondary Prevention

Rehabilitation should begin within 24-48 hours and include physical, occupational, and speech therapy as needed. Lifestyle modifications, including smoking cessation, limited alcohol intake, regular exercise, and a Mediterranean or DASH diet, are essential components. Some key points to consider in the management of stroke include:

• Mechanical thrombectomy is indicated for large vessel occlusions within 24 hours of symptom onset.
• Antiplatelet therapy should be initiated within 24-48 hours, typically with aspirin.
• Blood pressure management targets <140/90 mmHg using medications like ACE inhibitors or ARBs.
• Statin therapy is recommended regardless of baseline cholesterol levels.
• For atrial fibrillation-related strokes, anticoagulation with direct oral anticoagulants or warfarin should be initiated. However, these points are not directly supported by the most recent and highest quality study 1, which focuses on the importance of stroke unit care and interdisciplinary team assessment and management. In clinical practice, the approach to comprehensive management of cerebrovascular accident (CVA) or stroke should prioritize admission to a specialized stroke unit, rapid assessment and management by an interdisciplinary team, and initiation of rehabilitation and secondary prevention strategies to reduce recurrence risk and optimize recovery 1.

From the Research

Comprehensive Management of Cerebrovascular Accident (CVA) or Stroke

The approach to comprehensive management of cerebrovascular accident (CVA) or stroke involves several key components, including:

• Early identification and triage of patients to centers capable of delivering appropriate treatment 2
• Use of emergency medical services protocols for identification of patients with stroke 2
• Intravenous thrombolysis in acute ischemic stroke, including updates to recommended patient eligibility criteria and treatment time windows 2
• Advanced imaging techniques with automated interpretation to identify patients with large areas of brain at risk but without large completed infarcts who are likely to benefit from endovascular thrombectomy in extended time windows from symptom onset 2
• Management of patient physiologic parameters to minimize infarct volumes 2
• Secondary prevention recommendations, including short-term use of dual antiplatelet therapy to prevent recurrent stroke in the high-risk period immediately after stroke 2

Acute Stroke Management

Acute stroke management is moving from a universal time window approach to a concept of tissue preservation, specifically preserving cerebral blood flow, the penumbra, and reducing the risk of a second event 3. This movement is being executed through the use of multimodal CT and MRI, as well as individualizing treatment to patients 3. Endovascular thrombectomy (EVT), alone or combined with iv thrombolysis, is currently the most effective therapy for patients with acute ischemic stroke (AIS) 4.

Critical Care Management

Intensive care management of stroke is focused on reducing complications of reperfusion, such as hemorrhagic transformation, and minimizing secondary brain injury, including brain edema and progressive stroke 5. Severe stroke patients frequently need ventilatory or hemodynamic support provided in an intensive care unit (ICU) setting 5.

Rehabilitation

A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes 6. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation 6. The primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction 6.