What is the management and treatment for a patient with an ischemic Cerebrovascular Accident (CVA)?

Management and Treatment of Ischemic Cerebrovascular Accident (CVA)

For patients with acute ischemic stroke, immediate administration of intravenous alteplase (rtPA) 0.9 mg/kg (maximum 90 mg) within 3-4.5 hours of symptom onset is the cornerstone of treatment, followed by admission to a specialized stroke unit with intensive monitoring and early rehabilitation to reduce mortality and disability. 1, 2

Immediate Emergency Assessment and Stabilization

Time is brain—every minute counts. The first priority is rapid assessment and treatment initiation. 2, 3

• Stabilize airway, breathing, and circulation immediately, particularly in patients with depressed consciousness or bulbar dysfunction 1, 3
• Provide supplemental oxygen to maintain oxygen saturation ≥94% 3
• Check capillary blood glucose immediately and treat hypoglycemia with IV dextrose if present 3
• Document the precise time of symptom onset (or time last known normal if onset not witnessed)—this single piece of information determines all treatment eligibility 1, 2
• Perform rapid neurological examination using the NIHSS to quantify stroke severity within minutes of arrival 1

Urgent Neuroimaging

Obtain non-contrast CT brain imaging immediately—this is the single most critical diagnostic test to differentiate ischemic from hemorrhagic stroke before any treatment. 1, 2

• CT is faster and widely available; MRI is more sensitive for early ischemic changes but should not delay treatment if CT is available 4
• Do not delay imaging for laboratory tests 3

Intravenous Thrombolysis (rtPA)

This is the only FDA-approved treatment proven to improve clinical outcomes in acute ischemic stroke. 1, 5

Eligibility Criteria (within 3-4.5 hours of symptom onset):

• Diagnosis of ischemic stroke causing measurable neurological deficit 1
• No evidence of intracranial hemorrhage on CT 1
• Blood pressure <185/110 mmHg before treatment 1
• No recent major surgery, serious trauma, or GI/GU hemorrhage within 14-21 days 1
• INR ≤1.7, platelets >100,000/mm³ 1
• No multilobar infarction (hypodensity >1/3 cerebral hemisphere) on CT 1

Treatment Protocol:

• Administer 0.9 mg/kg (maximum 90 mg) over 60 minutes, with 10% given as bolus over 1 minute 1, 2
• The greatest benefit occurs when treatment is given as soon as possible—door-to-needle time should be <60 minutes 5
• Symptomatic intracranial hemorrhage occurs in approximately 6.4% of treated patients 1

Intensive Monitoring After rtPA

Admit to intensive care or stroke unit with 1:2 nurse-patient ratio for first 24 hours. 1

Blood Pressure Monitoring:

• Check BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly until 24 hours 1
• Maintain BP <180/105 mmHg during and for 24 hours after thrombolysis 1, 2
• If BP exceeds these limits, administer antihypertensive medications immediately 1

Neurological Monitoring:

• Perform complete NIHSS assessment every 15 minutes during infusion, every 30 minutes for 6 hours, then hourly until 24 hours 1
• Suspect hemorrhagic transformation if: change in level of consciousness, BP elevation, motor examination deterioration, new headache, nausea, or vomiting 1
• If hemorrhage suspected: discontinue rtPA immediately, obtain emergent CT, send coagulation studies, and prepare to administer 6-8 units cryoprecipitate and 6-8 units platelets 1

Bleeding Precautions:

• Avoid invasive procedures (arterial punctures, nasogastric tubes, indwelling catheters) for 24 hours 1
• Use soft sponges instead of toothbrushes for oral care 1
• Rotate automatic BP cuff sites every 2 hours; discontinue if petechiae develop 1
• Obtain follow-up CT at 24 hours before starting antiplatelet or anticoagulant therapy 1

Endovascular Therapy (Mechanical Thrombectomy)

For patients with large vessel occlusion in the anterior circulation, mechanical thrombectomy should be performed within 24 hours of symptom onset. 1

• Stent retrievers (Solitaire FR, Trevo) are preferred over coil retrievers (Merci) 1
• Patients eligible for IV rtPA should receive it even if endovascular treatment is planned—do not delay IV rtPA 1
• Intra-arterial therapy requires transfer to experienced stroke center with rapid access to cerebral angiography 1
• Time to reperfusion is directly correlated with outcomes—minimize all delays 1

Stroke Unit Care

All stroke patients should be admitted to a specialized stroke unit—this intervention alone reduces mortality and disability. 1, 2, 4

Essential Components:

• Dedicated, trained nursing staff with expertise in neurological assessment 1
• Interdisciplinary team including physicians, nurses, physical therapists, occupational therapists, speech therapists 2
• Cardiac monitoring for at least 24 hours to detect atrial fibrillation 2, 4
• Nurse-patient ratio of 1:4 after first 24 hours if stable 1

Prevention of Acute Complications

Aspiration Prevention:

• Perform swallowing screening within 24 hours using validated tool before any oral intake 4
• Keep patient NPO until swallowing safety confirmed 4
• If swallowing impaired, provide nasogastric or nasoduodenal feeding 1, 2

Deep Vein Thrombosis Prophylaxis:

• Apply intermittent pneumatic compression devices immediately for immobilized patients 1, 4
• Subcutaneous anticoagulants (unfractionated heparin or LMWH) are more effective than aspirin but carry bleeding risk 1
• Do not start anticoagulants or antiplatelet agents until 24 hours after rtPA and after follow-up CT rules out hemorrhage 1

Management of Cerebral Edema:

• Brain swelling typically occurs 3-5 days after stroke but can occur earlier with large MCA infarctions 1, 2
• Monitor for signs of increased intracranial pressure: declining consciousness, pupillary changes, motor deterioration 1
• Patients with NIHSS >20 are at highest risk for malignant edema 1

Antiplatelet Therapy

Administer aspirin 160-300 mg within 48 hours of stroke onset (but typically after 24 hours if thrombolysis was given). 2

• Aspirin reduces early recurrent stroke risk 2
• Do not give aspirin before brain imaging rules out hemorrhage 3

Early Rehabilitation

Begin rehabilitation assessment by specialized therapists within 48 hours of admission. 4

• Physical therapy for motor deficits 4
• Occupational therapy for activities of daily living 4
• Speech therapy for dysarthria or aphasia 4
• Early mobilization when medically stable 2

Secondary Prevention Workup

Cardiac Evaluation:

• Atrial fibrillation is a major risk factor—the most common cause of cardioembolic stroke 2, 6, 7
• Continuous cardiac monitoring for at least 24 hours 2, 4
• Echocardiography (transthoracic or transesophageal) to evaluate for cardioembolic source 4

Vascular Imaging:

• Carotid duplex ultrasound if carotid territory symptoms and patient is surgical candidate 4
• Consider advanced vascular imaging for multifocal strokes to identify embolic sources 2

Laboratory Studies:

• Lipid panel for statin therapy consideration 4
• Hemoglobin A1c if diabetes suspected 4

Long-Term Secondary Prevention

Initiate these measures before discharge—they are quality-of-care indicators. 1, 2

• Statin therapy regardless of baseline cholesterol levels 2, 4
• Antihypertensive therapy after acute phase (typically 24-48 hours post-stroke), target <140/90 mmHg 2, 4
• Anticoagulation for atrial fibrillation after ruling out hemorrhagic transformation 2
• Antiplatelet therapy (aspirin, clopidogrel, or combination) for atherosclerotic disease 4
• Diabetes management if present 4
• Smoking cessation 4

Critical Pitfalls to Avoid

• Never delay transfer for extensive diagnostic workup—time is the most critical factor 3
• Never give aspirin or anticoagulants before brain imaging rules out hemorrhage 3
• Never aggressively lower blood pressure in acute ischemic stroke unless BP >185/110 mmHg and patient is rtPA candidate 3
• Never use automatic BP cuffs continuously on same arm after rtPA—rotate sites to prevent hematoma formation 1
• Age >80 years increases hemorrhage risk after rtPA but is not an absolute contraindication—carefully weigh risks and benefits 1
• Patients with NIHSS >20 have 17% risk of symptomatic ICH after rtPA versus 3% for NIHSS <10—inform patients/families of this risk 1
• Deviations from treatment protocols increase hemorrhagic transformation risk—follow guidelines strictly 1