Treatment of Progressive Cerebrovascular Accident (CVA)
The treatment of progressive cerebrovascular accident (CVA) should focus on direct oral anticoagulants (DOACs) like rivaroxaban over standard-of-care anticoagulants for better outcomes in terms of reduced thrombus recurrence and improved thrombus resolution. 1
Initial Management
- For patients with progressive CVA, immediate assessment for cerebrovascular disease should be conducted, including MRI/MRA brain or spine to exclude structural causes and determine the type of stroke (ischemic vs. hemorrhagic) 1
- In cases of ischemic stroke, withhold any immune checkpoint inhibitors if the patient is on cancer therapy, as these can exacerbate neurological symptoms 1
- Comprehensive neurological examination should be performed to assess the severity and progression of symptoms 1
Anticoagulation Therapy
First-line Treatment
- For ischemic progressive CVA, DOACs (rivaroxaban/dabigatran) are suggested over standard-of-care anticoagulants (LMWH, UFH, VKAs, fondaparinux) 1
- Rivaroxaban shows better outcomes with reduced thrombus recurrence and improved thrombus resolution compared to standard anticoagulants 1
- Between rivaroxaban and dabigatran, either can be used, though individual factors and jurisdictional availability may influence the choice 1
Important Considerations
- Gastrointestinal side effects are more common with dabigatran and should be considered when selecting therapy 1
- For patients with severe symptoms or life-threatening progression, initiate intravenous methylprednisolone 2 mg/kg while involving a neurologist in care 1
- Daily neurological review and vital capacity assessment should be conducted for patients with severe symptoms 1
Cognitive Rehabilitation
Patients with progressive CVA should be assessed for cognitive deficits and provided with appropriate cognitive retraining for: 1
- Attention deficits
- Visual neglect
- Memory deficits
- Executive function and problem-solving difficulties
Training to develop compensatory strategies for memory deficits is beneficial for patients with mild short-term memory impairments 1
Multiple cognitive retraining approaches involving various disciplines may benefit patients with multiple areas of cognitive impairment 1
Management of Comorbidities
Screen for and aggressively manage vascular risk factors that can worsen stroke progression: 1
- Hypertension
- Diabetes mellitus
- Hypercholesterolemia
Regular assessment of fasting glucose is recommended for all stroke survivors, with screening for altered glucose metabolism beginning as part of survivorship care and repeated every 3 years 1
Special Considerations
Patients with Cancer
- Cancer patients receiving certain therapies (bevacizumab, sorafenib, carfilzomib) have higher risk of arterial thrombotic events including CVA 1
- In cancer patients with progressive CVA, the incidence of cerebrovascular events ranges from 2-5.9% depending on the therapy 1
- Consider withholding cancer therapies known to increase thrombotic risk during acute stroke management 1
Antiplatelet Resistance
- For patients showing progression despite antiplatelet therapy, consider testing for aspirin or clopidogrel resistance 1
- Approximately 25-30% of patients may show aspirin resistance, which is associated with higher risk of recurrent vascular events 1
Monitoring and Follow-up
- Daily neurological assessment for patients with severe symptoms 1
- Pulmonary function assessment for patients with progressive symptoms affecting respiratory function 1
- Consider involving physiotherapy, occupational therapy, and speech therapy as appropriate based on deficit areas 1
- For patients with visual-spatial deficits after right CVA, specific visual-spatial rehabilitation should be implemented 1
Pitfalls to Avoid
- Do not confuse costovertebral angle (CVA) tenderness with cerebrovascular accident (CVA) in documentation 2
- Avoid delaying treatment for progressive symptoms; early intervention is critical for limiting neurological damage 1
- Do not overlook the possibility of spontaneous coronary thrombosis following thrombolytic therapy for acute CVA 3
- Remember that female gender, older age (≥65), black ethnicity, and comorbidities including CHF, PVD, and atrial fibrillation are associated with higher risk of CVA progression 4