What is the diagnosis and treatment for a cerebrovascular accident (CVA) or stroke?

From the Guidelines

Stroke diagnosis and treatment should prioritize prompt identification and intervention, with a focus on minimizing morbidity, mortality, and improving quality of life, as emphasized in the 2023 systematic review and synthesis of global stroke guidelines 1. The diagnosis of a cerebrovascular accident (CVA) or stroke involves a comprehensive evaluation, including blood work, cerebral imaging, vascular imaging, and electrocardiographic monitoring, as outlined in the guidelines 1.

• Blood work should include complete blood count, prothrombin time, partial thromboplastin time, glucose, HbA1c, creatinine, and fasting or non-fasting lipid profile.
• Cerebral imaging with CT or MRI is recommended to identify the type and location of the stroke.
• Vascular imaging of the extracranial cervical arteries is recommended to identify patients with severe internal carotid artery stenosis who may benefit from urgent carotid endarterectomy or stenting.
• Electrocardiographic monitoring is essential to screen for atrial fibrillation, with at least 24 hours of cardiac monitoring recommended.

Treatment for ischemic strokes should include clot-dissolving medications like alteplase (tPA) if given within 4.5 hours of symptom onset, as recommended in the 2023 guidelines 1.

• IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 min with initial 10% of dose given as bolus over 1 min) is recommended for selected patients who can be treated within 4.5 h of ischemic stroke symptom onset or last known well.
• Patients with AIS who awake with stroke symptoms or have unclear time of onset >4.5 h from last known well, IV alteplase administered within 4.5 h of stroke symptom recognition can be beneficial if MRI shows DWI-FLAIR mismatch.
• Mechanical thrombectomy is recommended for patients with AIS within 6–24 h of time last known well who have a LVO in the anterior circulation, with advanced imaging (CTP or DW-MRI, with or without MRI perfusion) to determine eligibility.

Prevention of recurrent stroke involves controlling risk factors, such as high blood pressure, diabetes, high cholesterol, smoking cessation, maintaining healthy weight, regular exercise, and limiting alcohol consumption, as well as medications like antiplatelet drugs or anticoagulants, depending on stroke cause 1.

• Blood pressure management is essential, with treatment initiated as soon as possible after a stroke or TIA, or at least before discharge.
• Selection of antihypertensive drugs should be individualized, with angiotensin-converting enzyme-inhibitors combined with a thiazide diuretic recommended for patients with ischemic stroke or TIA.
• Rehabilitation, including physical, occupational, and speech therapy, is crucial for recovery and improving quality of life.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Diagnosis of Cerebrovascular Accident (CVA) or Stroke

• The diagnosis of stroke can be categorized as ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage 2
• Awakening with or experiencing the abrupt onset of focal neurologic deficits is the hallmark of the diagnosis of ischemic stroke 2
• The most common presenting symptoms of ischemic stroke are speech disturbance and weakness on one-half of the body 2
• Neuroimaging is required to differentiate ischemic stroke from intracerebral hemorrhage, as well as to diagnose entities other than stroke 2

Treatment Options for CVA or Stroke

• Management of acute ischemic stroke in the first hours is critical to patient outcomes, and treatment options include thrombolysis and endovascular therapy 3
• Dual-antiplatelet therapy (clopidogrel and aspirin) has been shown to reduce the risk of recurrent stroke and is not associated with increased risk of hemorrhagic events 4
• Apixaban, a new oral anticoagulant, has been proven to be as safe and effective as traditional anticoagulants while carrying significantly less risk of intracranial hemorrhage 4
• Clopidogrel plus aspirin was more effective than aspirin alone in reducing the risk for recurrent stroke (ischemic or hemorrhagic), but increased major bleeding events 5

Secondary Prevention and Management

• For patients with ischemic stroke despite anticoagulation, most respondents indicated that they obtain extracranial and intracranial vessel imaging 6
• Most respondents routinely change therapy to a direct oral anticoagulant (DOAC) for patients experiencing ischemic stroke while on warfarin 6
• In cases of ischemic stroke while on a DOAC, some respondents routinely switch agents, while others do not, citing a lack of randomized trial data 6