Treatment Plan for Acute Ischemic Stroke with Cerebral Amyloid Angiopathy
The best treatment plan for this patient with acute ischemic stroke in the left frontal lobe, cerebral amyloid angiopathy (CAA), and extensive paranasal sinus disease is immediate aspirin therapy (325 mg) within 24-48 hours, early mobilization as tolerated, comprehensive stroke unit care with specialized rehabilitation, and close monitoring for complications. 1
Immediate Management
- Protect airway, breathing, and circulation as the patient is currently non-communicative but breathing independently 1
- Monitor neurological status closely using standardized stroke severity assessment tools 2
- Administer aspirin 325 mg within 24-48 hours of stroke onset to reduce risk of early recurrent stroke 1, 3
- Avoid intravenous thrombolysis due to presence of cerebral amyloid angiopathy, which significantly increases risk of hemorrhagic transformation 4, 5
- Avoid anticoagulation therapy due to increased risk of intracranial hemorrhage in patients with CAA 4, 6
Management of Cerebral Amyloid Angiopathy
- Implement strict blood pressure control to reduce risk of intracerebral hemorrhage by up to 77% in patients with CAA 4
- Exercise caution with antiplatelet therapy due to increased bleeding risk, but benefits of aspirin in acute ischemic stroke outweigh risks 4, 3
- Avoid statin therapy if patient has history of lobar intracerebral hemorrhage, as this increases risk of recurrent hemorrhage from 14% to 22% 4
- Monitor for signs of CAA-related inflammation which may require corticosteroid treatment 7
Prevention of Complications
- Implement early mobilization as tolerated to prevent deep vein thrombosis, pulmonary embolism, and pressure sores 1
- Use intermittent external compression stockings to prevent deep vein thrombosis 1
- Perform swallowing assessment before allowing oral intake to prevent aspiration 1
- Consider nasogastric or nasoduodenal tube for feeding if swallowing is impaired 1
- Monitor for and promptly treat infections, particularly pneumonia and urinary tract infections 1
- Assess for seizures, especially given the patient's reduced level of consciousness 1
- Treat seizures if they occur but avoid prophylactic anticonvulsants 1
Rehabilitation Plan
- Transfer to a comprehensive stroke unit for specialized care as soon as medically stable 1, 2
- Implement early standardized assessment of somatosensory function to guide rehabilitation 2
- Provide cognitive retraining for attention deficits 2
- Arrange speech and language pathology evaluation for communication difficulties 2
- Implement touch discrimination training for somatosensory loss 2
- Provide positioning and supportive devices for any shoulder subluxation 2
- Avoid overhead pulley exercises 2
Management of Paranasal Sinus Disease
- Consult otolaryngology for evaluation of extensive paranasal sinus disease with chronic fungal colonization 1
- Monitor for signs of fungal infection spread, particularly given the patient's compromised state 1
Long-term Secondary Prevention
- Continue antiplatelet therapy (aspirin) for secondary stroke prevention 1
- Implement strict blood pressure control 1, 4
- Consider left atrial appendage closure rather than anticoagulation if atrial fibrillation is present 6
- Address all modifiable risk factors for stroke recurrence 2
Special Considerations for CAA with Ischemic Stroke
- Balance the benefit of antiplatelet therapy against bleeding risk in CAA 4, 5
- While intravenous thrombolysis in CAA patients may improve outcomes (increased odds of routine discharge by 77%), it significantly increases risk of intracerebral hemorrhage (4-fold) and subarachnoid hemorrhage (2.4-fold) 5
- Monitor closely for hemorrhagic transformation of the infarct, which is more common in patients with CAA 4, 5