What is the management of ischemic cerebrovascular accident (CVA) after the thrombolysis period has passed?

Management of Ischemic Stroke After Thrombolysis Window

For ischemic stroke patients presenting beyond the thrombolysis window, immediate admission to a dedicated stroke unit with comprehensive supportive care, early aspirin administration (within 24-48 hours), and aggressive secondary prevention measures form the cornerstone of management. 1

Immediate Acute Care Priorities

Stroke Unit Admission

• All patients should be admitted to a specialized stroke unit (a geographically defined hospital unit dedicated to stroke management) rather than general medical wards, as this consistently improves clinical outcomes and reduces mortality 1
• For critically ill patients, intensive care unit admission with nurse-to-patient ratio of 1:2 for the first 24 hours is recommended 1
• Cardiac monitoring for at least 24 hours is essential to screen for atrial fibrillation and serious arrhythmias 1

Antiplatelet Therapy

• Aspirin (160-325 mg) should be administered within 24-48 hours of stroke onset as it provides reasonable safety with small but meaningful benefit in reducing early recurrent stroke 1
• For patients with aspirin allergy, an alternative antiplatelet agent should be substituted 1
• Dual antiplatelet therapy (aspirin plus clopidogrel) may be considered for minor noncardioembolic strokes and should be converted to single antiplatelet therapy after 21-90 days 2

Medical Complications Prevention

Blood Pressure Management

• Blood pressure should be monitored but lowered cautiously - aggressive reduction can worsen cerebral perfusion 1
• Maintain blood pressure below 220/120 mm Hg unless other end-organ involvement is present 1
• Drug-induced hypertension to improve perfusion cannot be recommended outside research settings due to risks of hemorrhagic transformation, cerebral edema, and cardiac complications 1

Physiologic Parameter Control

• Body temperature monitoring is mandatory - fever (>38°C) must be treated aggressively as it worsens outcomes 1
• Blood glucose control - both hyperglycemia and hypoglycemia worsen outcomes and require correction 1
• Maintain adequate hydration to prevent dehydration which compounds ischemic injury 1

Venous Thromboembolism Prophylaxis

• Gradual early mobilization should be encouraged for all patients 1
• For patients with limited mobility, thigh-high intermittent pneumatic compression devices (IPC) are recommended 1
• Subcutaneous heparin or low molecular weight heparin may be used for DVT prophylaxis, though this does not reduce early stroke recurrence 1

Seizure Management

• Antiseizure medications are indicated ONLY for documented secondary seizures - prophylactic use is not recommended 1

Monitoring for Neurological Deterioration

Early Deterioration Risk

• Up to 30% of stroke patients deteriorate within the first 24 hours, necessitating intensive nursing observation 1
• Serial neurological examinations should be performed to identify worsening brain swelling 1
• Repeat head CT scan is indicated if clinical deterioration occurs 1

Signs Requiring Urgent Intervention

• Declining level of consciousness suggesting increased intracranial pressure 1
• New or worsening motor deficits 1
• Signs of herniation (pupillary changes, posturing, respiratory pattern changes) 1

Massive Stroke Considerations

Surgical Interventions

• Decompressive hemicraniectomy within 48 hours is indicated for patients <60 years with massive hemispheric infarction and worsening neurological condition - functional benefit is much greater in younger patients 1
• For cerebellar infarction with brainstem compression, ventriculostomy for obstructive hydrocephalus and/or decompressive suboccipital craniectomy may be life-saving 1
• Patients with massive strokes should be rapidly transferred to centers with neurosurgical expertise if their condition is deemed survivable 1

Secondary Prevention Evaluation

Diagnostic Workup

• Complete evaluation to determine stroke etiology should be initiated during hospitalization 1
• Vascular imaging (carotid Doppler, CT angiography, or MR angiography) to assess for significant stenosis 1
• Cardiac evaluation including transthoracic echocardiography to identify cardioembolic sources 1
• Laboratory assessment including lipid profile, hemoglobin A1c, and coagulation studies 3

Risk Factor Management

• Hypertension control is the single most important modifiable risk factor for stroke prevention 4
• Diabetes management with target HbA1c individualized but generally <7% 4
• Lipid management with statin therapy for most ischemic stroke patients 4
• Lifestyle modifications including smoking cessation, alcohol reduction, diet modification, and exercise 2

Rehabilitation Planning

Multidisciplinary Approach

• Early involvement of physical therapy, occupational therapy, and speech therapy 1
• Dysphagia screening before oral intake to prevent aspiration pneumonia 1
• Assessment for post-stroke depression, which is common and treatable 2
• Discharge planning should begin early with coordination of outpatient rehabilitation services 1

Critical Pitfalls to Avoid

• Do not routinely anticoagulate acute ischemic stroke patients outside specific indications (e.g., atrial fibrillation after appropriate timing) - urgent anticoagulation increases hemorrhagic transformation risk without reducing early recurrent stroke 1
• Do not aggressively lower blood pressure in the acute phase unless >220/120 mm Hg or other compelling indications exist 1
• Do not delay aspirin beyond 48 hours unless contraindicated 1
• Do not miss atrial fibrillation - ensure adequate cardiac monitoring as this fundamentally changes long-term anticoagulation strategy 1