What is the management of cerebrovascular accident (CVA) or stroke?

Management of Cerebrovascular Accident (CVA)

All patients with suspected stroke must be treated as a medical emergency with immediate triage to a specialized stroke unit, rapid neuroimaging within minutes of arrival, and consideration for reperfusion therapy (IV thrombolysis within 4.5 hours or mechanical thrombectomy up to 24 hours for selected patients), followed by comprehensive interdisciplinary care to reduce mortality and disability. 1, 2

Immediate Emergency Response and Triage

• Transfer immediately to an intensive care or stroke unit with neuromonitoring capabilities and skilled physicians (neurointensivists, vascular neurologists, neurosurgeons) for patients with large territorial strokes 3

• Stabilize airway, breathing, and circulation first—particularly critical in patients with depressed consciousness or large strokes 3, 4

• Document precise time of symptom onset as this is the single most important factor determining eligibility for reperfusion therapies 1, 4

• Perform rapid neurological assessment using the NIH Stroke Scale to quantify deficit severity 1, 4

• If comprehensive care and neurosurgical intervention are unavailable locally, arrange urgent transfer to a higher-level center; consider telemedicine links for remote consultation 3

Urgent Neuroimaging (Within Minutes)

• Obtain non-contrast CT scan immediately as the first-line diagnostic test to differentiate ischemic from hemorrhagic stroke and rule out hemorrhage before any treatment 3, 1, 2

• CT findings predicting cerebral edema include: frank hypodensity within 6 hours, involvement of ≥1/3 of MCA territory, and early midline shift 3

• MRI with diffusion-weighted imaging (DWI) is more sensitive for early ischemia; volumes ≥80 mL predict rapid fulminant course with malignant edema 3

• Serial CT scans in the first 2 days identify patients at high risk for symptomatic swelling 3

Acute Reperfusion Therapy

Intravenous Thrombolysis

• Administer IV alteplase (rtPA) 0.9 mg/kg (maximum 90 mg) immediately for patients presenting within 4.5 hours of symptom onset who meet eligibility criteria and have no contraindications 1, 4, 2

• Blood pressure must be maintained <180/105 mmHg during and for 24 hours after thrombolysis to prevent hemorrhagic transformation 1, 4

• Close monitoring for bleeding complications is essential during and after thrombolytic therapy 2

Mechanical Thrombectomy

• Consider endovascular thrombectomy for large vessel occlusions within 6-24 hours based on specific imaging criteria showing salvageable brain tissue 2, 5

• Combined stent-retriever and aspiration techniques achieve the highest rates of complete reperfusion 2

Airway and Mechanical Ventilation

• Indications for intubation include: persistent hypoxemia, obstructed airway with pooling secretions, apneic episodes, hypercarbic/hypoxemic respiratory failure, generalized seizures, or recent aspiration 3

• Use rapid sequence intubation; no evidence that depolarizing agents or propofol/fentanyl/lidocaine are harmful 3

• Maintain normocapnia—no benefit from prophylactic hyperventilation and potential harm 3

• Use short-acting sedatives (propofol or dexmedetomidine) in low doses for intubated patients who are alert enough to experience discomfort 3

Blood Pressure Management

For Patients NOT Receiving Thrombolysis

• Avoid antihypertensive treatment unless systolic BP >220 mmHg or diastolic >120 mmHg in the acute phase 2

• Elevated blood pressure should be lowered cautiously as it may be maintaining cerebral perfusion to ischemic penumbra 1

For Patients Receiving Thrombolysis

• Maintain BP <180/105 mmHg strictly for at least 24 hours after rtPA administration 1, 4

Long-term Management

• Start antihypertensive therapy 24-48 hours post-stroke with target <140/90 mmHg after the acute phase 1, 4

Antiplatelet and Antithrombotic Therapy

• Administer aspirin 160-300 mg within 48 hours of stroke onset, but delay until 24 hours after thrombolysis if rtPA was given 1, 2

• Anticoagulation is NOT recommended as standard acute treatment due to increased bleeding risk 2

• For patients with atrial fibrillation, consider anticoagulation only after ruling out hemorrhagic transformation (typically after several days) 1

Swallowing Assessment and Nutrition

• Perform swallowing screening within 24 hours using a validated tool before allowing any oral intake (food, fluids, or medications) 4, 2

• Keep patient NPO until swallowing safety is confirmed to prevent aspiration pneumonia 4

• For impaired swallowing, use nasogastric or nasoduodenal tube feeding to maintain nutrition 3

• Sustaining adequate nutrition and hydration is critical as dehydration may slow recovery and increase DVT risk 2

Prevention of Complications

Deep Vein Thrombosis Prophylaxis

• Apply intermittent pneumatic compression devices immediately for all immobilized patients 4, 2

• Use subcutaneous anticoagulants (low molecular weight heparin or unfractionated heparin) for immobilized patients 1

Pressure Ulcer Prevention

• Frequent turning, alternating pressure mattresses, and close skin surveillance prevent pressure sores 2

Infection Prevention

• Monitor aggressively for and treat pneumonia and urinary tract infections 1

Monitoring for Neurological Deterioration

• Monitor for cerebral edema, which typically peaks 3-5 days after stroke but can occur earlier with large infarctions 1

• Watch for seizures and hemorrhagic transformation 1

• Neurological status and vital signs should be assessed frequently during the first 24 hours 2

Management of Cerebral Edema and Increased Intracranial Pressure

• Corticosteroids are NOT recommended for cerebral edema after stroke 2

• Osmotic therapy (mannitol or hypertonic saline) and hyperventilation are recommended for patients who deteriorate from malignant edema 2

• Decompressive craniectomy with dural expansion should be considered for patients with large hemispheric infarcts who continue to deteriorate neurologically despite medical management 3

• Efficacy of decompressive craniectomy is uncertain in patients ≥60 years of age 3

• For cerebellar infarction with swelling: suboccipital craniectomy with dural expansion should be performed in deteriorating patients 3

• Ventriculostomy alone is contraindicated in cerebellar infarction—it must be accompanied by suboccipital decompression to avoid upward cerebellar herniation 3

Specialized Stroke Unit Care

• All stroke patients should be admitted to a geographically defined stroke unit with dedicated interdisciplinary staff trained in stroke management 3, 2

• Stroke unit care reduces mortality and morbidity with benefits comparable to IV thrombolysis and persisting for years 2

• Multidisciplinary team should include: physician, nursing staff, occupational therapist, physiotherapist, speech pathologist, dietician, social worker, and psychologist where possible 3

• Cardiac monitoring for at least 24 hours to screen for atrial fibrillation and arrhythmias 4, 2

Early Rehabilitation

• Begin rehabilitation assessment within 48 hours of admission by specialized therapists 4, 2

• Early mobilization when medically stable lessens complications (pneumonia, DVT, pulmonary embolism, pressure sores) 1, 2

• Physical therapy for motor deficits, occupational therapy for activities of daily living, speech therapy for language/swallowing deficits 4

• Cognitive rehabilitation should be provided for patients with attention deficits, visual neglect, memory deficits, or executive function problems 3

• Visual-spatial rehabilitation is beneficial for visual neglect after right hemisphere stroke 3

Secondary Prevention Workup

• Cardiac evaluation: ECG monitoring for at least 24 hours to detect atrial fibrillation; consider echocardiography (transthoracic or transesophageal) to evaluate for cardioembolic source 1, 4

• Vascular imaging: Carotid duplex ultrasound for carotid territory symptoms if patient is a surgical candidate 4, 2

• Laboratory: Lipid panel for statin therapy consideration 4

Long-term Secondary Prevention

• Initiate high-intensity statin therapy regardless of baseline cholesterol levels 1

• Carotid endarterectomy is recommended for 70-99% ipsilateral stenosis within 6 months of non-disabling stroke; consider for 50-69% stenosis in select patients 2

• Surgery should be performed as soon as possible, ideally within 2 weeks of the event 2

• Diabetes management if present 4

• Smoking cessation 4

Discharge Planning and Follow-up

• Early assessment and planning of discharge needs with family education about management, rehabilitation, causes, secondary prevention, and community resources 3

• Provide education on stroke warning signs (FAST mnemonic: Face drooping, Arm weakness, Speech difficulty, Time to call emergency services) and risk factor modification 1, 2

• Schedule regular follow-up to monitor neurological recovery and medication adherence 1

• Rehabilitation can be provided in stroke rehabilitation units, general rehabilitation units, outpatient settings, day hospitals, or community-based programs with equal effectiveness 2

Prognosis Considerations

• After decompressive craniectomy for hemispheric infarction, anticipate that one-third of patients will be severely disabled and fully dependent despite surgery 3

• Surgery after cerebellar infarction leads to acceptable functional outcome in most patients 3

• Mortality is increased in mechanically ventilated patients, though outcomes have improved with modern decompressive surgery 3