What is the treatment for Cerebrovascular Accident (CVA)?

Treatment for Cerebrovascular Accident (CVA)

For acute ischemic stroke, immediately administer intravenous tissue plasminogen activator (tPA) at 0.9 mg/kg (maximum 90 mg) if the patient presents within 3 hours of symptom onset and has no contraindications, followed by comprehensive stroke unit care, early rehabilitation, and aggressive secondary prevention to reduce mortality and improve functional outcomes. 1, 2

Immediate Emergency Management

Time-Critical Assessment

• Document the precise time of symptom onset as this determines eligibility for reperfusion therapies—this is the single most critical piece of information 1, 2
• Perform rapid CT imaging immediately to confirm ischemic stroke and rule out hemorrhage before initiating any treatment 1, 2
• Assess stroke severity using the NIH Stroke Scale to guide treatment decisions and prognosis 1
• Stabilize airway, breathing, and circulation, particularly in seriously ill or comatose patients 1

Reperfusion Therapy Decision Algorithm

For patients presenting within 3 hours:

• Administer IV tPA 0.9 mg/kg (maximum 90 mg) if no contraindications exist 1, 2
• This is a Class I recommendation with the strongest evidence for reducing mortality and disability 1

For patients presenting within 3-4.5 hours:

• Consider IV thrombolysis in eligible patients without extended contraindications 2

For large vessel occlusion:

• Consider mechanical thrombectomy if within appropriate time window, which can extend beyond the thrombolysis window in selected patients 2

Blood Pressure Management

• If thrombolysis administered: Maintain blood pressure <180/105 mmHg for at least 24 hours to prevent hemorrhagic transformation 1, 2
• If no thrombolysis: Cautiously lower elevated blood pressure, avoiding aggressive reduction in the acute phase 1, 2
• For hemorrhagic stroke: Target systolic blood pressure 130-150 mmHg 2

Acute Hospital Phase (First 48 Hours)

Antiplatelet Therapy

• Administer aspirin 160-300 mg within 48 hours of stroke onset 1, 2
• Critical timing caveat: If thrombolysis was given, delay aspirin for 24 hours to reduce bleeding risk 1

Stroke Unit Care

• Transfer all patients to a comprehensive stroke unit regardless of stroke severity—this intervention alone reduces mortality and improves functional outcomes 1, 2
• Implement early swallowing assessment before allowing any oral intake to prevent aspiration pneumonia 1
• For impaired swallowing, use nasogastric or nasoduodenal tube feeding to maintain nutrition 1

Complication Monitoring

• Aggressively monitor for and treat pneumonia, urinary tract infections, and deep vein thrombosis 1
• Watch for cerebral edema (peaks at 3-5 days but can occur earlier with large infarctions) 1
• Monitor for seizures and hemorrhagic transformation 1

Secondary Prevention (Initiated After Acute Phase)

Pharmacological Prevention

• Initiate statin therapy regardless of baseline cholesterol levels—this is a Class I recommendation 1, 2, 3
• Start antihypertensive therapy 24-48 hours post-stroke 1, 2, 3
• For atrial fibrillation: Consider anticoagulation after ruling out hemorrhagic transformation 1, 2
• For symptomatic carotid stenosis >70%: Consider carotid endarterectomy within 2 weeks 2

Anticoagulation for Specific Etiologies

For cerebral venous thrombosis (CVT):

• Initiate anticoagulation with IV heparin or subcutaneous LMWH even if intracranial hemorrhage is present—hemorrhage from CVT is NOT a contraindication 4
• Continue oral anticoagulation for 3-12 months depending on underlying etiology 4
• For transient reversible factors: 3-6 months 4
• For high-risk/inherited thrombophilia: lifelong anticoagulation 4

For progressive ischemic CVA:

• DOACs (rivaroxaban or dabigatran) are preferred over standard anticoagulants (LMWH, UFH, warfarin) for better outcomes with reduced thrombus recurrence 3

Rehabilitation and Recovery

Early Mobilization

• Begin early mobilization as soon as the patient is medically stable 1, 2
• Initiate physical, occupational, and speech therapy assessments immediately 2

Cognitive Rehabilitation

• Assess for cognitive deficits and provide cognitive retraining for attention deficits, visual neglect, memory deficits, and executive function problems 3
• Implement compensatory strategies for memory deficits in patients with mild short-term memory impairments 3

Prevention of Subacute Complications

• For immobilized patients, use subcutaneous anticoagulants, intermittent external compression stockings, or aspirin to prevent deep vein thrombosis 1
• Implement measures to prevent aspiration, malnutrition, pulmonary embolism, and pressure sores 1

Special Populations and Considerations

Pediatric Stroke (Cervical Artery Dissection)

• For extracranial cervical artery dissection in children, initiate UFH or LMWH as a bridge to oral anticoagulation 4
• Treat with subcutaneous LMWH or warfarin for 3-6 months (target INR 2.0-3.0) 4
• Alternatively, an antiplatelet agent may be substituted 4
• Continue antiplatelet agents beyond 6 months if radiographic evidence of residual arterial abnormality persists 4

Retinal Artery Occlusion

• Treat as a medical emergency with immediate referral to emergency department or stroke center 4
• Risk of concurrent cerebral stroke is 20-24% and risk of subsequent stroke is highest within first 7 days 4
• Consider hyperbaric oxygen therapy (100% oxygen over 9 hours) which has demonstrated efficacy in small randomized trials 4
• For giant cell arteritis: Administer corticosteroids immediately 4

Multifocal Ischemic CVA

• Perform thorough cardiac evaluation including ECG monitoring for at least 24 hours to detect atrial fibrillation 1
• Consider advanced vascular imaging to identify potential embolic sources 1
• Screen aggressively for vascular risk factors including hypertension, diabetes mellitus, and hypercholesterolemia 3

Critical Pitfalls to Avoid

• Never delay imaging to obtain detailed history—time is brain 1, 2
• Never withhold anticoagulation in cerebral venous thrombosis even if hemorrhage is present—this is a common and dangerous misconception 4
• Never aggressively lower blood pressure in acute ischemic stroke unless thrombolysis is given—this can worsen outcomes 1, 2
• Never allow oral intake before swallowing assessment—aspiration pneumonia significantly increases mortality 1
• Never assume older patients should not be referred for acute stroke evaluation—age alone should not determine treatment eligibility 4, 1