What are the management steps for a patient with a Cerebrovascular Accident (CVA)?

SOAP Notes for the Management of Cerebrovascular Accident (CVA)

Immediate management of a patient with suspected CVA should follow published guidelines for emergency stroke care, including rapid assessment, stabilization, thrombolytic therapy for eligible patients, and implementation of initial preventive therapy. 1

Subjective

• Document onset time and duration of symptoms 1
• Record specific neurological deficits reported by patient or witnesses 1
• Note risk factors: hypertension, diabetes, hyperlipidemia, smoking, atrial fibrillation 2
• Document previous stroke or TIA history 1
• Record current medications, particularly anticoagulants or antiplatelets 2

Objective

Initial Assessment

• Vital signs with focus on blood pressure (target varies based on stroke type) 2
• Complete neurological examination using standardized stroke scale (e.g., NIHSS) 2
• Immediate neuroimaging (CT or MRI) to differentiate ischemic from hemorrhagic stroke 2
• Laboratory tests: complete blood count, coagulation profile, electrolytes, glucose, renal function 3
• ECG to identify cardiac arrhythmias 2

For Ischemic Stroke

• Assess eligibility for thrombolytic therapy (time window, contraindications) 2
• Evaluate for large vessel occlusion that may require mechanical thrombectomy 2
• Screen for carotid stenosis with carotid imaging 1

For Hemorrhagic Stroke

• Assess for signs of increased intracranial pressure 2
• Evaluate coagulation status, especially if on anticoagulants 2
• Consider neurosurgical consultation 2

Assessment

• Specify stroke type: ischemic (embolic, thrombotic, lacunar) or hemorrhagic 2
• Identify vascular territory affected 1
• Assess stroke severity using standardized scale 2
• Determine time of onset for treatment window considerations 1
• Evaluate for stroke mimics (e.g., seizures, migraine, hypoglycemia) 4, 5
• Identify potential etiology (cardioembolic, large vessel atherosclerosis, small vessel disease) 2

Plan

Immediate Management (First 24 Hours)

For Ischemic Stroke:

• Administer intravenous thrombolysis (tPA) if within appropriate time window (typically 3-4.5 hours) and no contraindications 2
• Consider mechanical thrombectomy for large vessel occlusion if within appropriate time window 2
• Maintain blood pressure <180/105 mmHg if thrombolysis administered 1, 2
• For non-thrombolysis patients, allow permissive hypertension (systolic BP up to 220 mmHg) initially unless contraindicated 2
• Position patient with 20-30° head-up tilt 1

For Hemorrhagic Stroke:

• Control systemic hypertension with goal systolic BP 130-150 mmHg 2
• Reverse anticoagulation if applicable 2
• Consider neurosurgical intervention for cerebellar hemorrhage or significant mass effect 2
• Monitor for signs of increased intracranial pressure 2

Ongoing Management

Neurological Monitoring

• Perform regular neurological assessments to detect early deterioration 3
• Monitor for complications: cerebral edema, hemorrhagic transformation, seizures 2

Medical Management

• Initiate antiplatelet therapy (typically aspirin 325mg initially, then 81mg daily) for ischemic stroke after ruling out hemorrhage 2
• Manage blood glucose (target 140-180 mg/dL) 3
• Maintain normothermia 2
• Prevent deep vein thrombosis with early mobilization or prophylactic anticoagulation 2
• Ensure adequate hydration with isotonic fluids (0.9% saline preferred in brain injury) 1

Respiratory and Nutritional Support

• Maintain oxygen saturation >94% 1
• If intubated, aim for PaO₂ ≥13 kPa and PaCO₂ 4.5-5.0 kPa 1
• Consider dysphagia screening before oral intake 2
• Initiate enteral nutrition within 24-48 hours if unable to take oral diet 2

Secondary Prevention

• Initiate statin therapy regardless of baseline cholesterol 2
• Start antihypertensive therapy after acute phase (typically 24-48 hours post-stroke) 2
• Consider anticoagulation for atrial fibrillation after ruling out hemorrhagic transformation 2
• For symptomatic carotid stenosis >70%, consider carotid endarterectomy within 2 weeks 1

Rehabilitation

• Begin early mobilization when medically stable 2, 6
• Initiate physical, occupational, and speech therapy assessments 6
• Address specific deficits: motor, sensory, language, cognitive, visual 3, 6
• Consider occupational adaptation interventions to improve functional independence 6

Discharge Planning

• Assess need for rehabilitation facility versus home with services 2, 6
• Provide education on stroke warning signs and risk factor modification 1
• Schedule appropriate follow-up with neurology, primary care, and rehabilitation services 2
• Ensure medication reconciliation and adherence plan 2

Common Pitfalls and Considerations

• Failure to recognize stroke mimics can lead to inappropriate treatment (common mimics include seizures, migraines, metabolic disorders) 4, 5
• Delayed treatment significantly reduces effectiveness of thrombolysis and thrombectomy 1
• Inadequate blood pressure management can worsen outcomes in both ischemic and hemorrhagic stroke 1, 2
• Overlooking dysphagia can lead to aspiration pneumonia 2
• Neglecting to screen for atrial fibrillation may miss an important cause of cardioembolic stroke 2, 7
• Failure to recognize post-MI stroke risk, particularly in patients with heart failure, atrial fibrillation, or those undergoing CABG 8