What is the treatment for an acute Cerebrovascular Accident (CVA) in an 85-year-old patient presenting more than 24 hours after symptom onset?

Treatment of Acute CVA in an 85-Year-Old Presenting After 24 Hours

For an 85-year-old patient presenting 24 hours after acute ischemic stroke onset, thrombolytic therapy (IV alteplase) is contraindicated, but highly selected patients may still benefit from endovascular thrombectomy (EVT) up to 24 hours if they meet specific advanced imaging criteria, while all patients should receive supportive care including aspirin, DVT prophylaxis, and admission to a stroke unit. 1

Immediate Assessment and Management

Initial Evaluation

• Perform rapid assessment of airway, breathing, and circulation to ensure physiological stability 2
• Maintain oxygen saturation ≥94% with supplemental oxygen if needed 2
• Check capillary blood glucose immediately and treat hypoglycemia with IV dextrose 2
• Obtain non-contrast CT head urgently to differentiate ischemic from hemorrhagic stroke 1

Blood Pressure Management

• Avoid aggressive blood pressure lowering in ischemic stroke unless BP is extremely elevated or patient has concurrent acute myocardial ischemia, aortic dissection, or preeclampsia 2
• For hemorrhagic stroke with hypertension, consider lowering systolic BP to target of 140 mmHg 2

Revascularization Therapy Considerations

Thrombolytic Therapy (IV Alteplase)

• IV alteplase is NOT indicated at 24 hours post-onset - the standard window is 4.5 hours, though highly selected patients with unknown onset time may be considered using MRI DWI-FLAIR mismatch criteria 1
• The 2009 AHA/ASA guidelines extended the window to 3-4.5 hours (excluding patients >80 years, NIHSS >25, those on anticoagulants, or with combined history of stroke and diabetes) 1
• At 24 hours, this patient is well beyond any thrombolytic window 1

Endovascular Thrombectomy (EVT)

• Highly selected patients may benefit from EVT up to 24 hours if they meet specific imaging criteria 1
• Requires consultation with stroke neurologist and neurointerventional team 1
• Patient must undergo advanced neurovascular imaging including CT angiography (CTA) to identify large vessel occlusion (LVO) 1
• Additional perfusion imaging (CTP or MRI perfusion) is required to demonstrate salvageable brain tissue (penumbra) in the extended 6-24 hour window 1
• The Canadian Stroke Best Practice guidelines note that randomized trials demonstrated benefit of EVT up to 24 hours in patients selected using CTP or diffusion-weighted MRI criteria showing favorable perfusion-diffusion mismatch 1

Standard Medical Management

Antiplatelet Therapy

• Administer aspirin 160-325 mg daily once hemorrhagic stroke is excluded by CT, to reduce stroke mortality and morbidity 1
• Do NOT give aspirin before brain imaging rules out hemorrhage 2
• Aspirin should be given within 48 hours of symptom onset 1

DVT Prophylaxis

• Initiate subcutaneous low molecular weight heparin or unfractionated heparin for DVT prophylaxis in immobilized patients 1
• This reduces DVT risk though benefit for pulmonary embolism prevention is not clearly demonstrated 1
• Continue prophylaxis for patients remaining immobile beyond 30 days 1
• Anti-embolism stockings alone are not recommended 1

Supportive Care Measures

• Admit to designated stroke unit with specialized stroke protocols 1
• Monitor temperature every 4 hours for first 48 hours; treat fever >37.5°C with antipyretics and investigate for infection 1
• Perform swallowing screening before oral intake using validated tools 1
• Begin early mobilization within 24 hours if medically stable, with frequent brief out-of-bed activity 1
• Initial rehabilitation assessment by therapists within 48 hours of admission 1
• Ensure adequate hydration 1

Seizure Management

• Treat new-onset seizures with short-acting medications (e.g., lorazepam IV) if not self-limiting 1
• Do NOT use prophylactic anticonvulsants - evidence suggests possible harm with negative effects on neurological recovery 1
• A single self-limiting seizure within 24 hours of stroke onset should not be treated with long-term anticonvulsants 1

Critical Pitfalls to Avoid

• Do not administer IV alteplase at 24 hours - this is well beyond the approved window and increases hemorrhage risk without benefit 1
• Do not give antiplatelet or anticoagulant therapy before CT excludes hemorrhage 2
• Do not aggressively lower blood pressure in ischemic stroke - this may worsen cerebral perfusion 2
• Do not use IV heparin or high-dose LMWH for acute stroke treatment - these are not recommended for reducing morbidity, mortality, or early recurrent stroke and may increase bleeding complications 1
• Do not delay EVT evaluation if LVO is suspected - even at 24 hours, selected patients may benefit if imaging criteria are met 1

Special Considerations for This Patient

Age-Related Factors

• The ECASS-3 trial that extended the thrombolytic window to 4.5 hours specifically excluded patients >80 years 1
• However, age alone should not exclude consideration for EVT if imaging criteria are favorable 1
• Elderly patients may have increased bleeding risk but can still benefit from appropriate acute stroke interventions 1

Diagnostic Workup

• Complete blood count, electrolytes, coagulation studies 2
• ECG to identify atrial fibrillation or other arrhythmias 2
• Vascular imaging (carotid duplex, CTA, or MRA) for secondary prevention planning 1
• Echocardiography if cardioembolic source suspected 1